POR
Registration Number: 063-18
PSPC
Contract Number: 51019-181009/001/CY
Contract
Award Date: December 19, 2018
Delivery
Date: April 24, 2019
Contracted
Cost: $46,121.85
Client Experiences with Veterans Affairs Canada Rehabilitation
Program and Case Management Services
Final Report
Prepared by:
Corporate
Research Associates Inc.
Prepared for:
Veterans Affairs Canada
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rapport est aussi disponible en français.
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more information on this report, please email:
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Client
Experiences with Veterans Affairs Canada Rehabilitation Program and Case
Management Services
Final Report
Prepared for Veterans
Affairs Canada
Supplier Name: Corporate Research Associates Inc.
April 2019
This public opinion research report presents the results of in-depth
interviews conducted by Corporate Research Associates Inc. on behalf of Veterans
Affairs Canada (VAC). The research study included a total of 29 in-depth
telephone interviews with VAC clients who were currently or had received Case
Management Services and/or taken part in the Rehabilitation Services and
Vocational Assistance Program. All had completed the 2017 VAC National Survey
and expressed an interest in follow-up research. Interviews were conducted from February 27 to April 2, 2019.
Cette publication est aussi disponible en
français sous le titre : Expériences des clients avec le Programme de
réadaptation et les services de gestion de cas d’Anciens Combattants Canada.
This publication may be reproduced for non-commercial purposes
only. Prior written permission must be obtained from Veterans Affairs Canada.
For more information on this report, please contact Veterans Affairs Canada
at: vac.information.acc@canada.ca
Catalogue Number:
V49-10/2019E-PDF
International Standard Book Number (ISBN):
978-0-660-31562-1
Related publications (registration number:
POR-063-18):
Catalogue Number V49-10/2019F-PDF (Final Report, French).
ISBN 978-0-660-31563-8
© Her Majesty the Queen in Right of Canada, 2019
Table of Contents
Veteran’s Experiences with Case Management Services
Veterans’ Experiences with Rehabilitation Services and
Vocational Assistance Program..
Appendix A: Recommendations for Survey Items on Future Iterations
of the VAC National Survey
Appendix C: Political Neutrality Statement
Appendix D: Recruitment Screener
Appendix E: Interview Protocol
Appendix F: Background Documents
Executive Summary
Corporate
Research Associates Inc.
Contract
Number: 51019-181009/001/CY
POR
Registration Number: 063-18
Contract
Award Date: December 19, 2018
Contracted
Cost: $46,121.85
To support improvements to service delivery and policy
development, in the spring of 2017 Veterans Affairs Canada (VAC) conducted the
VAC National Survey 2017 to obtain feedback from War Service Veterans, CAF
Veterans and Members, RCMP Veterans and survivors who were either in receipt of
benefits or who had applied for a benefit in the last 12 months. While the
survey demonstrated overall satisfactory results, aspects of the Rehabilitation
Services and Vocational Assistance Program and Case Management Services received
lower ratings. As such, further exploration was needed to better understand the
reasons for lower satisfaction levels.
In January 2019 VAC commissioned Corporate Research Associates
Inc. (CRA) to conduct qualitative research with Veterans who took part in the 2017
VAC National Survey. The goal of this study was to explore areas of lower
satisfaction from the 2017 VAC National Survey, specifically related to the
Case Management Services and the Rehabilitation Program. A total of 29 in-depth
telephone interviews were conducted from February 27, 2019 to April 2, 2019.
Research objectives:
·
Explore clients’ perceived experiences
with their engagement in the Rehabilitation Program and/or Case Management
Services;
·
Identify the facilitators and barriers to
clients’ participation in the Rehabilitation Program and/or Case Management
Services;
·
Identify the facilitators and barriers to
clients’ completion of the Rehabilitation Program and/or Case Management
Services.
The study also sought to make recommendations for
survey items on future iterations of the VAC National Survey, and future
research to support the development, management and improvement of programs and
services for Veterans and their families.
Findings from this qualitative research study will be
used to increase VAC’s understanding of clients’ experiences with these
specific programs/services, inform the development of survey items on future
iterations of the VAC National Survey, and inform future research to support
the development, management and improvement of programs and services provided
to Veterans and their families. Qualitative techniques are used in marketing research as a means
of developing insight and direction, rather than collecting quantitatively precise
data or absolute measures. As such,
results are directional only and cannot be projected to the overall population
under study.
What Did Veterans Tell Us?
Transitioning
from Military to Civilian Life
Veterans
begin their case management experience at a time of physical pain, mental
instability, with trepidation and uncertainty for their future. This and the
fact that military culture is significantly different than civilian culture
defines particular needs for the Veteran.
Awareness
and Understanding of VAC’s Services and Programs
Veterans are often unaware of, or do not understand the suite of VAC’s programs and services available to them, and are unsure where to access this information. This is sometimes a function of the Veteran’s personal physical and mental circumstances that make it difficult to absorb and navigate information and sometimes a function of the complexity of VAC’s system. Often both factors are at play. Therefore, Veterans want a clear and structured Case Plan. This points to the need for clear, complete, direct and accessible information, delivered pro-actively to the Veteran and it emphasizes the need for the Case Manager to act as both an advocate and a navigator for the Veteran for both VAC programs and community resources.
Case
Manager Role - Characteristics, Knowledge and Skill Set
Veterans
do not fully understand the Case Manager role and experience variability in
quality and experience levels in Case Managers. Veterans identify key qualities
and ideal characteristics as: being empathetic, understanding, caring, having
excellent listening skills and an ability to build rapport. Veterans expect
that Case Mangers will be knowledgeable about all of VAC’s benefits and
services and will proactively communicate this information to Veterans. There
is the perception among some Veterans that Case Managers may withhold
information, thus acting as gate-keepers.
Working
Relationship Between Veteran and Case Manager
Veterans
want direct access to their Case Manager and they want continuity in the
working relationship. Change is experienced as disruptive and potentially
harmful to the Veterans’ well-being. Veterans express a fear of the future and
seek a safety net, sometimes expressed as a desire to retain Case Management services
and remain in the Rehabilitation program, even when the Veteran is deemed well
enough to cease services.
Experiences
with Rehabilitation Services and Vocational Assistance Program
Veterans
have experienced excellent outcomes as a result of participating in medical,
psychosocial and vocational rehabilitation programs, however Veterans
identified issues in the program that stem from both individual and structural
(VAC) sources. The connection between rehabilitation and financial security is one
that requires further exploration. This and Veterans’ fear of the future and
want of a safety net, combined with what is perceived as a lack of
accountability may account for Veterans remaining in the Rehabilitation program
even when they are determined to be well. Veterans have good awareness of
medical and psychosocial rehabilitation programs, but not for vocational
rehabilitation. Veterans experience confusion between the Service
Income Security Insurance Plan (SISIP) offered by the Canadian Armed Forces
and the Vocational Assistance program offered through VAC.
Introduction
A core responsibility of Veterans Affairs
Canada (VAC) is to support the care and well-being of Veterans and their
families through a range of benefits, services, research, partnerships and
advocacy. Case management and rehabilitation services are two core offerings of
VAC, each of which was explored in detail in the VAC National Survey in 2017,
as outlined below.
Case
Management Services
VAC Case Management services enable
Veterans with complex needs, and their families, to achieve mutually agreed
upon goals through a collaborative, organized and dynamic process, coordinated
by the VAC Case Manager. VAC Case Managers are members of interdisciplinary
teams and have access to doctors, nurses, physiotherapists, occupational
therapists, mental health specialists, rehabilitation specialists, and
provincial and local programs and service providers. The Veteran and Case
Manager’s working relationship begins as soon as the Veteran and VAC Case
Manager meet. Initially, the Case Manager and Veteran identify and establish
goals or the Veteran’s case plan, as well as the facilitators and barriers to
achieving these goals. Throughout the
course of the case management process the Case Manager will work with the
Veteran to monitor and evaluate their progress and adjust the plan as necessary
to assist the Veteran and their family reach goals, and optimize the Veteran’s
level of independence and well-being.
Rehabilitation
Services and Vocational Assistance Program
The rehabilitation services and vocational
assistance program (rehabilitation program) was initiated after the
implementation of the New Veterans Charter on April 1, 2006. The rehabilitation
program provides services to support Veterans improve their physical,
psychosocial, and vocational well-being. Depending on individual needs and
goals, the Veteran works with a Case Manager to establish a rehabilitation plan
to address identified barriers to their function at home, in their community or
at work. Access to services can include medical
rehabilitation, psychosocial rehabilitation, and vocational rehabilitation.
Qualitative
Research
To support improvements to service delivery and policy development,
in the spring of 2017 Veterans Affairs Canada (VAC) conducted the VAC National
Survey 2017 to obtain feedback from War Service Veterans, CAF Veterans and
Members, RCMP Veterans and survivors who were either in receipt of benefits or
who had applied for a benefit in the last 12 months. The National Survey aimed
at gathering information on Veteran health and well-being and the extent to
which programs are effective in meeting recipients’ needs.
The VAC National Survey 2017 was designed to provide high level
information on degrees of satisfaction with VAC services and benefits. While
the survey demonstrated overall satisfactory results, aspects of the Rehabilitation
Services and Vocational Assistance Program (hereinafter referred to as the Rehabilitation Program) and Case Management Services received
lower ratings. As such, further exploration was needed to better understand the
reasons for lower satisfaction levels.
With this in mind, VAC commissioned Corporate Research Associates
Inc. (CRA) to conduct qualitative research with Veterans who took part in the
National Survey 2017 to explore areas of lower satisfaction, specifically
related to the Case Management Services and the Rehabilitation Program. VAC
will use the research findings to:
·
Increase VAC’s understanding of clients’
experiences with these programs/services;
·
Inform the development of survey items for
future VAC National Surveys; and
·
Inform future research to support the
development, management and improvement of programs and services provided to
Veterans and their families.
More specifically, the objectives of the
qualitative follow-up research project are as follows:
·
Explore clients’ perceived experiences
with their engagement in the Rehabilitation Program and/or Case Management
Services;
·
Identify the facilitators and barriers to
clients’ participation in the Rehabilitation Program and/or Case Management
Services;
·
Identify the facilitators and barriers to
clients’ completion of the Rehabilitation Program and/or Case Management
Services.
·
Make recommendations for survey items on
future iterations of the VAC National Survey, and for future research to
support the development, management and improvement of programs and services
for Veterans and their families.
Findings from this study will be used to
increase VAC’s understanding of clients’ experiences with these specific
programs/services, inform the development of survey items on future iterations
of the VAC National Survey, and inform future research to support the
development, management and improvement of programs and services provided to
Veterans and their families.
Research Methodology
Target
Population
The
target population consisted of Canadian Veterans, specifically the
sub-population of VAC clients who were currently in receipt of Case Management
Services and/or who participated in the Rehabilitation Program, or those who
had recently completed receiving this service, or program.
Discussion
Guide Design
The
interview protocol was developed by Corporate Research Associates in close
consultation with Veterans Affairs Canada. The final interview protocol is
appended to this report (Appendix D). Interview questions/topics are in part based
on background information provided by Veterans Affairs Canada (as found in
Appendix E of this report).
Data
Collection
A
total of 29 in-depth telephone interviews were conducted with VAC clients between February 27 to April 2, 2019. Each interview lasted approximately one hour (ranging from 40
minutes to 1 hour and 20 minutes). Of the 29
interviews, four
were conducted in French and 25 in English based on each client’s preferred
language. Participants represented a cross section of geographic locations
across Canada.
Sample
Participants
were randomly recruited from a VAC-provided list of individuals from the target
audience, as identified above. Only those who completed the VAC
National Survey 2017 and expressed an interest to take part in follow-up
research were considered for this study. All participants were recruited by telephone, per the
recruitment specifications for the Government of Canada. Participants were offered a financial
compensation of $75 in appreciation for their time.
The
following provides a breakdown of interviewees based on their current or past
participation to the Case Management Services and the Rehabilitation Program
(based on their self-identification):
|
|
Current |
Past |
Total |
|
Case
Management Services |
13 |
16 |
29 |
|
Medical
Rehabilitation |
10 |
9 |
19 |
|
Psycho-social
Rehabilitation |
9 |
10 |
19 |
|
Vocational
Rehabilitation |
0 |
4 |
4 |
In
total, 9 females and 20 males took part in the research. The following provides
an overview of the age breakdown of participants:
|
Age
Category |
Number
of Participants |
|
30-39
years old |
8 |
|
40-49
years old |
6 |
|
50-59
years old |
13 |
|
60-69
years old |
2 |
In
total 20 interviews were conducted with Veterans who currently reside in a
rural community, while nine interviews were conducted with those located in an
urban centre. The following table provides a breakdown of interviews by region:
|
Region |
Number
of Participants |
|
Atlantic
Canada |
8 |
|
Quebec |
3 |
|
Ontario |
10 |
|
Western
Canada/Prairies |
8 |
Analysis
Approach
Corporate
Research Associates consultants reviewed notes and recordings from the
interviews to assist with the analysis of research findings. In reviewing the
information obtained during the interviews, commonalities and differences among
responses were identified, as well as overarching themes. In addition, the
analysis incorporated the frequency occurrence, combining outward comments
expressed by respondents. As qualitative research is not statistically
representative, a calculation of frequencies only provided direction on areas
that require critical focus during the analysis and actual frequencies were not
included in the report.
Context
of Qualitative Research Approach
Qualitative
discussions are intended as moderator-directed, informal, non-threatening
discussions with participants whose characteristics, habits and attitudes are
considered relevant to the topic of discussion.
The primary benefits of individual or group qualitative discussions are
that they allow for in-depth probing with qualifying participants on
behavioural habits, usage patterns, perceptions and attitudes related to the
subject matter. This type of discussion
allows for flexibility in exploring other areas that may be pertinent to the
investigation. Qualitative research
allows for more complete understanding of the segment in that the thoughts or
feelings are expressed in the participants’ “own language” and at their “own
levels of passion.” Qualitative
techniques are used in marketing research as a means of developing insight and
direction, rather than collecting quantitatively precise data or absolute
measures. As such, results are
directional only and cannot be projected to the overall population under study.
Findings
Veteran’s Experiences with Case Management Services
Veterans
were asked to share perceptions of their Case Management experience, including
initial case manager assignment, the ongoing working relationship with their
case manager, the development of a case plan, and Case Management
communications.
1.
Transitioning from Military to Civilian Life
Regardless
of region, conversations highlighted that for many Veterans the transition from
a structured military life to a civilian life, where there is often no
structure at all or guidance, is often a shock.
For most, having to adapt to a non-regimented civilian lifestyle is
compounded by the fact that Veterans are typically dealing with serious
physical and mental conditions at the time of discharge, as a result of their
service. Again, while this aspect is beyond the scope of the Case Management
Services, the research shows that it has a significant influence on Veterans’
perceptions of that service.
“…I
was in the military one day, and I was out the next day. There has to be a
longer span when people can go and start working or being integrated into
civilian aspects to understand how things work. There is no hierarchy anymore.
People need to learn that the whole planning process, it’s not organized. It’s
very disorganized. Military people cannot handle disorganization and lack of
preparation. They need to learn slowly how to move from a structured
environment to a chaotic environment.”
“There
has to be some sort of mechanism in place to ease the transition from the
Canadian Forces to civilian [life] in a more managed pace. Don’t throw a person
at a psychologist three months after being released because it is not the same.
It is outside the whole scope for VAC but there should be a “one-stop centre”
for everything; VAC, SISIP, the CF release centre.”
Accordingly,
for many Veterans, integration into a civilian lifestyle presented real
challenges given their mental and physical state at the time. Apparent simple
tasks such as filling out documentation, or finding a civilian doctor proved
problematic for some, as such responsibilities were things typically taken care
of for them by the Canadian Armed Forces (CAF) when they were in service. Veterans also reported that these tasks were
further exacerbated by memory loss, mental challenges, being highly medicated,
or an unfamiliarity with what processes are required. This underscores the important advocacy role
of a case manager, especially at the onset of the relationship with clients.
Most
Veterans interviewed were generally satisfied with their assignment of a case
manager following discharge. Overall,
initial assignments were deemed to be timely and met Veterans’ expectations,
with assignment typically taking place within an acceptable timeframe
immediately following discharge.
“I
would say I was assigned a case manager pretty much right off the bat.”
That
said, a number of Veterans believed consideration should be given to having a
case manager assigned prior to or at
discharge to ensure a smoother transition and to provide increased
clarity during the transition process. Indeed, these Veterans would have liked
to have had their medical file and other relevant information regarding their
SISIP case transferred from the Canadian Armed Forces to Veterans Affairs
Canada to inform their case manager, avoid having to repeat medical
examinations, and ensure a smoother transition from the CAF. While this element
is beyond the scope of the Case Management Services, it was perceived by Veterans
as having a significant impact on their level of satisfaction with the Case
Management Services.
“When
you leave the military, it happens really fast and there is no one to navigate;
no one to tell you what services are available. You are in limbo the first few
months. Being assigned a case manager prior to discharge would be helpful; or
[being provided] a number to call when you have questions. I was going back to
the base and they couldn’t answer my questions.”
While
few problems were identified in relation to the timeliness of case management
assignment, some Veterans expressed confusion in terms of understanding the
process following discharge, the role of the case manager, and the full
spectrum of programs and services available for Veterans. In addition, a number of Veterans felt it was
not clear to them what services are and are not covered by VAC, most notably
with respect to medical services.
2.
Awareness and Understanding of VAC’s Services and Programs
Veterans
Affairs Canada’s (VAC’s) Case Management was considered by Veterans who took
part in the study as a highly important and valued service, especially in
guiding a Veteran as they leave the Canadian Armed Forces and try to regain
normalcy in their lives.
There
appeared to be some confusion as to the extent of the services offered by Case
Management Services, notably in terms of knowing what service is available, and
receiving assistance to apply for those benefits.
Veterans’
reactions were mixed when asked if their case manager proactively recommended
VAC benefits and programs. Some felt
that their case manager effectively communicated the full spectrum of programs
and services available and proactively offered suggestions and guidance.
“They
were good to explain; good to contact me. I asked for things I was not entitled
to and they were good at explaining why I could not access those.”
“The
communication aspect worked very well. If I requested information, she got back
within a reasonable time. Information on benefits was good. She was open and
quick [to respond].”
Other
Veterans criticized case managers for offering a more limited and subjective
range of services. Indeed, a good number
of Veterans were under the impression that their case manager did not openly
discuss the full range of options, but rather recommended only the assistance
or resources that they felt the Veteran needed, based on their initial review
of a Veteran’s case. More so, these
recommendations were sometimes made in absence of any conversation with the Veteran
or the Veteran’s family. While Veterans appreciated the guiding nature of this
type of interaction, they expressed a desire for more open and complete
communication.
“One
of the biggest hurdles is the transparency of information. The information that
the Vet needs about the program isn’t widely available to them. If I went on
Google and searched “VAC Rehab”, I don’t get an official site; I get people’s
testimonials, not official. There is no detail from VAC online… I found out
[about programs and services] because when I was released, I worked near the
VAC office so I was constantly asking them questions. That is how I found out
about it.”
Regardless
of their level of satisfaction with their case manager, Veterans highlighted a
need for increased and more complete communication on the full range of
benefits and services available to them in a simplistic, reference
document. While online access to this
kind of information was also suggested by a few, the importance of a simple,
printed document was considered paramount particularly given the fact that many
Veterans reported experiencing mental or emotional challenges at the time when
information is initially needed and may be unable to absorb and understand
information shared verbally. Having a
printed reference document that can be shared with others, referred to at a
later date, and that does not place the onus on the Veteran to search out the
information, was deemed by Veterans as both essential and currently
lacking. Further, some Veterans indicated
that they were not ‘tech savvy’ and were often overwhelmed by complex
government websites and difficult site navigation. Nonetheless, a tool
available both in print and online was considered important.
“It
would be good to have a web page to talk about all of the treatments available,
and the results. Present all of the facts in an unbiased way. That way, a
Veteran can make an informed decision. It needs to present all of the facts,
not just what the department thinks is the best approach.”
“[They
need to] ensure that Veterans know what they are entitled to, and what is
required of them throughout the various steps.”
For a
few Veterans, awareness of eligible programs, resource and services often
occurred through discussions with other Veterans or through civilian medical
personnel they were seeing. This was a point of frustration for some,
suggesting that VAC was not committed to ensuring Veterans had full awareness
and access to benefits that they are entitled to. A few Veterans saw their case manager as
someone ‘holding the purse strings’ in terms of deciding what should be offered
to a Veteran, rather than as an advocate for the Veterans and what they needed.
When
considering community resources that may be available to Veterans, with very
few exceptions, Veterans indicated that their case manager had not
informed them of any such community resources.
Further, most were unaware that this was actually a responsibility of a
case manager. In most cases Veterans
were either unaware of any community resources that might be available to them
or had only heard about such resources by chance or through communication with
other Veterans.
“I
live in a small rural community and I don’t think there would be anything. But
when I did live in the bigger cities, I wasn’t told of any [community programs
or services].”
Across
locations, Veterans discussed the importance of having clear, succinct and
simplistic communication with their case managers. Many expressed frustrations with a lack of
simple communication or broad overview related to Veterans’ benefits and
services, and felt the system is complicated and overly complex to navigate. As
mentioned, this is further compounded by a Veteran’s poor mental state at the
time of discharge. The system was
criticized for its inability to clearly outline necessary information in a
format that is easily understandable and can be quickly referenced at a later
date.
Veterans
felt strongly that case managers should present a complete overview of all
program and service options available, discuss the various advantages and
disadvantages of each option, and collaboratively decide what is the best
course of action with the Veteran’s best interests in mind. While this was the approach reportedly
experienced by some Veterans, many indicated that they experienced otherwise.
Further,
during that discussion, it was deemed imperative that Veterans fully understand
what impact specific actions would have on their various benefits. For example, if certain benefits would be
lost if a Veteran started a specific program, that consequence must be clearly
articulated and understood. Across locations, Veterans underscored the need to
use simple language in written communication regarding benefits, program
allowances or any decisions pertaining to a Veteran’s case. In a few instances,
Veterans felt that VAC currently uses a formal and technical language in its
personal written communications with Veterans.
“J’ai entendu dire que si tu manques trop de
rendez-vous, tu te fais sortir du programme. Je trouve ça aberrant parce que me
sentir fatiguée comme j’étais, je trouve ça normal qu’il y ait des absences ŕ
des rendez-vous.” (I
heard that if you miss too many appointments, you are taken out of the program.
I find this appalling because feeling tired as I was, I find it normal that
there would be missed appointments.)
3.
Case Manager Role - Characteristics, Knowledge and Skill Set
While
some felt that their case manager supported their effort to access VAC and
community services, others were unclear as to what case managers were
responsible for and what Case Management Services entailed. This lack of clear
understanding of the role of case managers may have contributed to some Veterans’
frustration towards the service. Conversely, a clear understanding of the role
of case managers led to Veterans being more satisfied with the service.
Across
interviews, Veterans’ Case Management experiences varied considerably. Those
who reported the greatest level of satisfaction with their engagement in the
service reported having had an attentive, caring and involved case manager who
they felt advocated for them and who took care to build a strong rapport.
“My
current one we have a really productive thing [going on]. He always calls every
month or month and a half to check on me and we set up time for home visits.
Any problem or question I have; I can just call him and he responds really
quickly. He will let me know about home visits; he likes to do it once a year.”
Veterans’
level of engagement in, and satisfaction with, the Case Management Services
appeared to be influenced by their level of understanding of the process, but
also with the case managers’ ability to create a strong rapport with their
clients. Indeed, across locations, Veterans consistently underscored the
importance of any case manager being understanding, empathic and respectful. More so, it was felt that a case manager must
be considerate of Veterans’ situation, compassionate of what Veterans are going
through and caring in all dealings with a Veteran. Ideally, it was felt a case manager should be
an advocate for Veterans, someone to help Veterans navigate through various
resources and information. Consistently, those who qualified their relationship
with their case manager as such were pleased with the service they received. By
contrast, a lack of perceived empathy and caring was often cited to explain
dissatisfaction.
Assuming
that advocacy role, a case manager’s listening skills were deemed imperative,
as was their ability to ensure that communication is provided in a format that
is fully understood and easily comprehendible. Further, it was suggested that
the skillset needed for case managers should include experience in the medical
sector or social services, with a special understanding of how to deal with
complex mental health issues.
Despite
uniformity in opinions on what a case manager should be like, findings suggest
inconsistencies in the level of service offered to Veterans. While some Veterans
were pleased with the professionalism and quality of service offered by their
case manager and considered the relationship to be exceptionally strong, others
felt their case manager lacked some of the essential qualities that are needed
to build rapport. Veterans’ perception of their case manager’s ability to build
rapport and establish a trusting relationship with them appeared to highly
influenced their perceptions regarding the quality of the service they
received.
“The
first case manager took the time to go through my medical record and outline
the issues and discussed with a doctor about something she was unsure of. She
took time to invest in me. To understand my situation. She was laid back, not
all uptight. I have had a couple of case managers that were so pushy; but she
wasn’t. She was taking time to understand what my position was and helped me
along to reach my goals. She was more on top of following up on things. She
would contact me every four to six weeks.”
“They
never pushed me; they offered me suggestions and contact information and not
once they told me I had to do this. Both [case managers] were totally great in
understanding [my situation].”
“She
cared about my needs and she was always wondering how the family was and how I
was and how I was doing with my goals.”
“[She
showed] empathy; advocating for me instead of me trying to prove my case. It
was like she was going to do everything possible to help streamline [the
process] and get all the benefits I was entitled to.”
Veterans
noted considerable variability in both the quality and experience of case
managers. Many Veterans prefaced their
comments about their case manager working relationships by noting that they
have had dramatically different experiences with different case managers. Such
inconsistencies in service delivery were attributed to: different
personalities, varied backgrounds and capabilities of case managers; a lack of
continuity in case managers; and a difference in accessibility offered by
part-time and full-time case manager resources.
There
is a widespread perception among Veterans that case managers are overworked,
bearing excessive and perhaps unrealistic workloads. Veterans were under the impression that case
managers’ workload impacts their performance, including the level of contact
they have with Veterans, and their ability to consistently review a Veteran’s
progression and offer counsel advice.
“I
have been very fortunate. I ended up getting two really good case managers. I
talk to other Vets that have other case managers that are way too busy. I know
mine is busy, but he will even email or text after work to make sure everything
is ok.”
4.
Working Relationship Between Veteran and Case Manager
Perhaps not surprising given Veterans’
highly structured lifestyle while in the service, Veterans voiced a clear
desire for a regimented schedule of contact with their case manager. Further,
given some Veterans’ compromised mental state, they expressed a desire for a
plan of action that does not present uncertainty and surprises. They expressed a desire to know what they can
expect as they work through their progress, and want to ensure that the contact
schedule is reviewed on a regular basis and adjusted as necessary. Those who
have had positive working relationships with their case manager generally
believed that their relationship has helped them stay better informed on how to
access the VAC programs and benefits that they need. In fact, many cited their
case manager’s suggestions and assistance as being fundamental to their effective
receipt of services and programs. By
contrast, those who experienced a less than ideal working relationship felt the
contrary. For them, they did not believe
that they received the necessary program and service information in a timely
fashion (if at all), or did not feel as though their case manager was
effectively looking out for their best interests.
Change
in Case Manager:
A good
number of Veterans indicated that they had worked with multiple case
managers. All Veterans fully appreciated
the heavy workload and limited number of case managers available and understood
that changes in staffing may occur. That said, a number of Veterans shared incidences
where they had not been informed of a change in their case manager and had only
found out when they reached out in need of assistance.
“I
kept getting new [case] managers; 3 or 4 managers. I lost tract of how many I
have had. It is a lot when you are not really told who the new one is. So, I
could not do much about telling them about my progress.”
Dissatisfaction
with the Case Management Services included having had to deal with multiple
case managers who offered various levels of services. Specifically, many
Veterans reportedly used the services of a number of different case managers
over time, noting an inconsistency in service delivery. In general, findings
suggest that Veterans appear more satisfied with the service if they dealt with
few case managers over the course of the program.
For
some, losing a ‘good’ case manager caused anxiety as they had to re-develop a
working relationship with another case manager – often times sharing details
and revisiting traumatic occurrences in their lives. The need to repeatedly
provide all detailed information to the new case manager was considered
troublesome and an ineffective use of everyone’s time. Many were left with the
impression that VAC does not have a transition process in place, as the new
case manager were not always familiar with the Veteran’s case. It was believed
that a better transition process should be implemented, and that involved Veterans,
in addition to providing advance notice of the change to Veterans when
possible.
“Over
the course of about 3 ˝ years, I had about three case managers. The first one
was good, but she left on mat leave. Then I had no case manager. Then I ended
up with a case manager that was 2 hours away and it was not easy to see her. I
talked to her a couple of times over the phone and that was it. Then I had no
case manager for a while. I was given another case manager [nearby] and she was
later posted [in another province] so we had a couple of phone calls, and
that’s it. I went to call her one day to find out something and I happened to
find out that she was no longer my case manager. I had called the 800 VAC line
and they told me she was no longer my case manager. Some case managers don’t
want to give you their direct line.”
Desire
to Retain Case Manager – Continuity of Care:
Once
finished their case plan, some Veterans would like to have the option of
keeping their file open, or retaining a case manager, just in case they need to
reach out at some time in the future to access additional services. This would
provide a ‘safety net’ for some, including reassurance that assistance would be
available if needed. It was mentioned that the current situation may be a
reason why some Veterans slow down program completion, so as to retain the
service of a case manager for as long as possible.
“I
think that a Veteran should have a case manager ongoing. Every Veteran should
have a point of contact that they can reach out to. Who at least has met you
and has a file on you. You may never have to have that
point of contact, but if you need it, it’s there.”
Access
and Contact with Case Manager:
Some Veterans
were frustrated by the fact that they are unable to contact their case manager
directly. The use of My VAC Account/ Mon dossier ACC was limited among
Veterans. Many were unfamiliar with
using the system and reported that they had not been properly trained on
it. Others indicated that they do not
like to use the system and found it cumbersome to deal with online formats. Some indicated that they prefer to have a
more personal relationship with an established contact. For them, their case is a personal matter
that they would like to be able to discuss one-on-one within an established
relationship.
Having
a direct phone number or email was clearly preferred to having to call a
general phone line and it was felt the current system is not set up to be
responsive to Veterans’ needs. Veterans disliked that they have to consistently
prove who they are when calling the general line, and having to wait for a
response from their case manager once a message is left with them. While the
process appears simplistic to them, they reported that it introduced a layer of
stress for those with mental challenges caused by stress.
“They
will not do any contact via email. You have to go through the MyVAC messaging system. It is a pain […] because you have
to log in and certify who you are and send a message which goes to a generic
forwarder and then to your case manager and it takes a day or two to get back a
response.”
“The
biggest problem I had is when you phone in I have to prove who I am and I can’t
contact the case manager directly. I get the run around and then have to leave
a phone message.”
“…I
am a digital person. I prefer things over email, but they won’t do that. If I
give my consent for them to contact me by email, it should not be an issue, but
they only want me to use MyVAC because of
confidentiality. But if the client prefers email and consent to it, there
should not be an issue.”
Across
the country, Veterans in more remote locations typically experienced greater
challenges in maintaining regular access to their case manager, as well as to
various programs and services. Some also
expressed concern for not having access to a French case manager given their
remote location, despite the fact that French was their mother tongue.
When
considering communication and accessibility, it is important to note that
numerous Veterans felt that VAC’s heightened focus on confidentiality impedes
its service delivery and is detrimental to Veterans getting the service they
need. More specifically, Veterans were
frustrated by not being able to have direct access to their case manager by
phone or email. Having to call the
toll-free number and leave a generic message was considered problematic and
unrealistic in a time of electronic service provision. While Veterans appreciated the importance of
confidentiality, and understood that a direct dial may not expedite access,
they felt strongly that a case manager’s email address should be provided. This would not only eliminate a key source of
frustration to many, but would provide a direct line of communication to the
case manager that would allow for more regular and timely communication.
“The
undue concern for my privacy was really creating a burden for me. Even if I
signed all of the waivers, it still had too many barriers [to contact my case
manager directly].”
“Before
anybody is given the opportunity to go back to school or learn a trade, I think
that the case manager and the treating person should communicate directly and
see if everybody is on the same page. It’s only a waste to send someone on a
course who is not ready to go. There were conversations every quarter between
my case manager and my therapist to fill them in on treatment and the level of
progression. But they did not get involved in telling the case manager when I
was ready. They could not pass on more information than the progression to my
case manager because of confidentiality.”
When
asked what the preferred level of contact between case managers and Veterans
should be responses varied notably depending on both a Veteran’s specific
needs, and the stage of their case plan.
That said, Veterans would like to see various types of contact,
including regular phone calls on a weekly or monthly basis and in-person
meetings annually. Consistently, an
in-person meeting was considered important to help establish an effective
ongoing relationship, and an important component to build rapport.
“The
fact that they came to my residence [was great]. That is not a norm for them
but they did accommodate me that way.”
Following
that, it was generally felt that having initially a weekly contact by phone was
important to assist the Veteran during an important transition period. While it was believed that the ongoing
frequency of contact should be totally dependent on any given case, it was felt
that moving to phone contact once every month or two and then progressing to
meeting in person once or twice a year would likely suffice. More importantly,
it was felt that the frequency of contact should be established in
collaboration with Veterans, and Veterans should be informed of that level of
contact upfront to align expectations. It should be noted that expectations on
the level of contact were generally consistent among both rural and urban Veterans. While it was appreciated that distance may
prove challenging in having regular in-person contact, the importance of such
contact for those living in remote areas was deemed of great importance given
the isolation that Veteran would be experiencing.
“Someone
who doesn’t have a head injury, once a week would be fine to get them doing
stuff; just a phone call [would be ok].”
“At
the beginning of a critical injury, it should be once a week. When you have no
one and that’s the only contact [you have], it’s important [to have] someone
looking out for you.”
A few
Veterans expressed frustration with the responsiveness they had experienced
with their case manager. As an example, one
Veteran felt that they ‘fell through the cracks’ and were made lower priority
because they appeared to be high functioning.
As a result, they consistently experienced delays in responsiveness.
5.
Development of a Case Plan
For
the most part, Veterans who had a case plan developed in recent years recalled
having been involved in this process and many were pleased with the manner in
which it unfolded, especially if they had an engaged case manager. Veterans who
were involved in the process typically described the involvement as a
discussion with the case manager regarding what realistic personal outcomes
might be, based on their physical and mental condition.
“We
set up a plan of where we are going to strive towards and work towards. And
every few months, we would follow up and see how things were going; see if we
had to adjust anything. My role was to come up with the ideas and the goals
that we were going to strive towards, and she would listen and input feedback
on if I was trying to strive for too much… For me, thinking about the goals
myself was a bit difficult but she guided me through and helped me pin point what
I needed to achieve.”
The
exception included those who reportedly did not have the mental capacity or
were in a poor physical state at the time the case plan was developed. Those Veterans typically had no clear
recollection of what involvement they may have had at that time. A few also
began Case Management Services more than a decade ago, and as such, had limited
recollection of what steps they initially went through.
Most
Veterans with a case plan were offered the opportunity for their family or support
network to be involved. This appeared to be more consistently the case for
Veterans who started Case Management Services within the past few years. This
process was generally appreciated by Veterans, and was felt to be an important
step in their active participation in the program. For some, a spouse played a
key role in case management and case plan discussions, primarily because of a
Veteran’s limited mental capacity at that time.
“My
wife was involved in every call and every meeting. She backed me up. My memory
fades in certain areas, and I might make light of things that are more serious
so [my wife] is my sounding board.”
That
said, a few Veterans, (namely among those without mental impairment),
questioned what value there would be in having family or a support network
involved in the development of a case plan. This suggests that there may be
merit in case managers more clearly articulating why such involvement could be
considered, so the Veteran can decide the best course of action for their
situation.
For
some Veterans, the case planning process was not clear. It appeared to them as though there was no
formal structure in place and the plan was in large part based on informal
conversations with a case manager.
Further, a good number of Veterans, particularly those who started the
process more than ten years ago, reported that no written document was
provided. No Veterans mentioned having a written case plan document as a
reference. This suggests that increased
focus on a more structured or formal plan could help to align Veterans’
expectations and understanding of the case plan process.
“I
did not know there was a formal case plan.”
Given
that Veterans are sometimes in a bad state when their case plan is being
developed, (i.e. physical pain or limited mental abilities), Veterans believed
they were not always in optimal condition to actively participate to developing
plan objectives. With that in mind, Veterans
felt that it would be worthwhile to revisit the case plan mid-point during rehabilitation
to ensure objectives are still aligned with expectations. Further, while some
discussed their progress with their case manager during rehabilitation, no one
reportedly had reviewed their initial objectives.
“Me
and my case manager we sat down and discussed [the case plan] and created a
path. It was difficult at the time because I was just at the beginning of the
transition from military to civilian [life]. That is not where my head was at.
I was upset about being released from the military.”
It is
interesting to note that some Veterans indicated that they are unsure what
their goals actually were / are, suggesting that efforts could be considered to
enhance communication to Veterans of their actual plan and corresponding goals.
Further, no Veteran had received a printed copy of their case plan. Accordingly, they had nothing to reference
their personal progress at any point, other than through conversations they may
have had with their case manager.
6.
Facilitators to Participation and Completion of Case Management
Services
When
considering the effectiveness of Veterans’ working relationship with their case
manager, and their level of engagement in Case Management Services, those with
positive experiences typically associated similar attributes to the
relationship. These consistently
included the following:
Regular
communication: As mentioned above, Veterans believe that communication is key in
establishing a good working relationship. The frequency of communication is
ranging from short-term to more long-term scheduled contact, as discussed
earlier in this report.
Proactive
support:
Whereby the case manager reached out to the Veteran on a regular basis, without
being prompted, showing genuine concern and interest in the Veteran’s progress,
and proactively suggesting services or programs that may assist Veterans based
on their unique and evolving needs. For
many Veterans, a positive relationship was often attributed to their case
manager’s proactive nature, namely reaching out to make sure the Veteran was
aware of a change in service or a benefit that might be relevant. A discussion
to simply ‘find out how things are going’ was often mentioned by Veterans as a
productive step in the Case Management Services.
Accessible: It was believed that a functioning
working relationship entails that Veterans are able to access their case manager
when they need to, and that they receive prompt response to their queries.
Accessibility and responsiveness were seen as going hand-in-hand.
Key personality attributes:
As mentioned earlier, Veterans who are pleased with their case manager
cited that they are empathetic, caring, looking out for Veterans’ best
interests and respectful of the Veteran’s ability to take on more. In the best-case scenarios, the case manager
provided invaluable moral support for the Veteran and was considered paramount
to the Veteran’s ongoing progression and improvement.
7.
Barriers to Participation and Completion of Case Management
Services
By
contrast, many Veterans cited less than ideal case management experiences which
in turn negatively impacted their experience of the Case Management Services and,
in some instances, their level of personal engagement. Reasons for challenging case management
experiences were generally attributed to the following:
Personality: Some case managers were not
considered to have the necessary skillsets in dealing with Veterans,
particularly due to a lack of compassion, understanding, respect or empathy.
Similarly, some Veterans criticized case managers for not wanting to engage
with the Veteran on the full range of benefits they were entitled to and being
directive in what benefits they should be told about. These attitudes were seen
by Veterans as a sign of not caring for their well-being, thus resulting in
some Veterans not being interested in actively participate in their
rehabilitation.
Responsiveness: Being non-responsive or untimely in
response to a Veteran’s outreach caused frustration. Some spoke of days or
weeks in response time to a basic query.
Change in
Case Managers:
Frustration was also evident among Veterans who had not been advised of a
change or switch in case manager. Further, when experiencing a change in case
manager, Veterans were frustrated by having to review their entire case history
with a new case manager, rather than the VAC system providing a complete case
overview.
Part-time
vs. Full-time Case Manager: Part-time resources were considered less responsive to Veterans’
needs and for some, accessibility proved problematic given the case manager’s
limited hours. Other Veterans found it
difficult to establish a relationship or receive frequent communication from a
part-time case manager.
Lack of
Communication Across Resources: Some lack of communication between case managers and treatment
staff was evident according to Veterans, resulting in not being aware of the
Veteran’s progress / new developments. For example, one Veteran mentioned not
being physically or mentally able to go to a physiotherapy appointment that is
scheduled a day or so apart from an appointment with their psychiatrist in
instances where the treatment session was particularly difficult. It was
mentioned that better understanding was required on the part of case managers
to adapt their expectations and manage that of healthcare providers, in those
kinds of situations. It was also mentioned that healthcare professionals and
case managers should work more closely in assessing a Veteran’s condition, to
ensure the proper level of case and adequate services (e.g., vocational) are
offered to align with the Veteran’s condition.
Lack of
Accessibility: Not being able to reach a case manager was
commonly cited as a point of frustration with the service.
Lack of Familiarity of Programs / Services: In many instances, Veterans were not
told of programs / services / benefits that they are entitled to because of
what was seen as a case manager’s lack of awareness.
Veterans’
Experiences with Rehabilitation Services and Vocational Assistance Program
Veterans
who are currently participating in the Rehabilitation Program, or those who
have completed the Program, were asked to share their perceptions about the
Program and to comment on their level of personal involvement.
1. Outcomes of Participation
With few exceptions, Veterans believe
that participating in Rehabilitation Services and Vocational Assistance Program
has resulted in a decrease in mental and physical barriers faced. As mentioned,
Veterans were generally confident that much of their success can be attributed
to the various programs and the benefits that they are able to access through
VAC. Key improvements typically centered
around improved moods / positive outlook, an increased understanding of how their
bodies and minds have reacted to their conditions, increased mobility
(particularly with the introduction of appliances and as a consequence of
surgeries), all of which resulted in a more settled life.
“As
far as quality of life goes it probably [did not help] as much as I expected.
But it has showed me where my problem areas are and ways to overcome stuff.”
For most Veterans, the Rehabilitation
and Vocational Assistance Program has been paramount in helping Veterans return
to daily activities. Whether addressing
various mobility challenges, easing integration into society (e.g. driving,
going in public, etc.), helping to lessen dependence on drugs or alcohol. For others the programs have resulted in
improved relationships with their spouse or other family members and allowed
them a greater sense of financial security.
“My
spouse is happy because he sees me improving. There is improvement in intimacy
– both physical and mental. I have the ability to hold a meaningful
conversation.”
A number of Veterans acknowledged that some barriers have not and will
never decrease, regardless of the level of rehabilitation programs they
participate in. Most notably, the fact
that they are disabled, or coping with significant mental challenges was
considered insurmountable to some. For others, a broken marriage, family life
or relationship has created a life-long barrier. Further, it was felt that a lack of
understanding or uncertainly of the future outlook of their psychosocial state
was a barrier to recovery. Veterans
often spoke of how their triggers still exist, and that it is their personal
reaction to those triggers that will continue to impact the stability in their
home and with their relationships.
Psychosocial
Rehabilitation:
In psychosocial rehabilitation, Veterans consistently reported that
they are now able to function on their own to a greater extent than when they
began treatment. While they acknowledged that they are a ‘mere shell of their
former self’, and that they will never fully recover from their PTSD, memory
loss, or depression, multiple changes for the better have been experienced. For
some, improvement has been most evident in: their ability to interact with
others (including their spouse or family members); a decreased dependence on
medication or alcohol; a more positive outlook; ability to manage anger; and
reduced depression. Having a better understanding of how to personally deal
with a traumatic or stressful event was also another key outcome from their
rehabilitation. In particular, accepting
that their condition is and will be ongoing for years (if not for their entire
life) was considered key in dealing with their situation.
“It helped me understand my barriers and understanding what I can
do. It gave me experience trying to overcome the symptoms I need to overcome. I
am more aware of my limitations.”
“I am getting proper and timely therapy for mental health. It has
taken me to a better place, helped me to keep the chaos away.”
For some, the ability to go out in public was often mentioned as
an area of improvement, as was being more independent, and being able to drive
down the road without an overwhelming fear of being shot at or worrying about
roadside bombs. Getting out of the house
more, but within the boundaries of their own shortcomings, was also seen as a
direct result of the rehabilitation whereby Veterans ventured outside their
home and expanded their borders.
“I wouldn’t go to local stores before. I am still restricted, but
now I venture out. We go for drives now. The biggest thing is it helped me
recognize that expanding the borders is a good thing.”
While public interaction continued to be a daily challenge to
many, Veterans spoke of being stronger mentally, being more social, not
thinking about dying to the same extent, having fewer suicidal thoughts, and
spending more quality time with their family.
In addition, Veterans have developed a greater understanding of how
their body is reacting to PTSD, including greater coping mechanisms.
Multiple Veterans underscored the importance of social interaction
in their improvement, and how their rehabilitation helped to recreate a social
life which added to consistency in their day-to-day life.
In a few instances, Veterans indicated that some VAC programs had
the potential to have a negative impact on Veterans. Specifically, it was reported that health
care offices or professionals were not set up to properly deal with PTSD.
Medical
Rehabilitation:
Veterans cited numerous improvements as a result of their medical rehabilitation. For many, such
rehabilitation has followed numerous surgeries, appliances, and extensive
physiotherapy. The greatest improvement
mentioned was increased mobility whereby Veterans are now able to leave their
house, be more independent and for some, live independently. Indeed, the use of appliances, and support
dogs were seen as significant positive contributors. Once again Veterans cited a more positive
outlook on life as a result of their increased mobility, as well as a reduced
dependency on drugs and alcohol to manage both physical and psychological pain.
“My mental state improved. My mobility to a certain extent. They
helped me a lot with doing things and learning things. My back is bad and I
learned how to minimize pain. The exercises they gave me helped.”
“I am mobile now; I am living in my house; I am no longer
dependant on drugs the way I was; my outlook is better.”
For many, once VAC had processed all medical conditions, Veterans
were able to get the financial benefits they were entitled. It was believed that this in turn reduced the
significant financial burden on Veterans and their family. Similarly, being exposed to the benefits that
are available helped Veterans with their basic needs and helped them to achieve
a better standard of living, especially for those who would not be able to work
again. This typically resulted in
significant financial improvements, a notable reduction of stress in the
household, including allowing some to keep their home.
A number of Veterans reiterated that the benefits they received
through the various programs provided the financial security to resolve their
debts, and in one instance, avoid personal bankruptcy.
Vocational
Rehabilitation:
Across locations it was rare that Veterans had made use of
vocational rehabilitation. As mentioned,
most were not yet in a position physically or mentally where vocational
rehabilitation was an option. For
others, their physical or mental state resulted in them being in a diminished
earning capacity, and thus would not likely return to gainful employment. Many
also confused SISIP and VAC vocational rehabilitation. Nonetheless, the few who
experienced the VAC vocational rehabilitation indicated that it helped them
transition to the civilian workforce, secure employment, and regain a sense or
normalcy at home.
“It helped my quality of life, my reassurance of finding
employment. I had really good support.”
One Veteran mentioned that the financial benefit differential
between the school periods and the work-term/co-op period caused some financial
difficulty. More specifically, the benefit amount adjustment was not provided
in a timely manner, which caused the family issues in financially planning for
fixed expenses. This was considered problematic when someone’s earnings changed
between school periods and coop periods, during which their earnings changed.
“I had to submit my paystubs to VAC and then they would do an
earnings loss recalibration calculation. From the time I would mail in one it
takes time to go to VAC so there is mail there and then the length of time it
takes them to recalculate and mail back to me. By that time, I have an
overpayment. Sometimes, it would take a three-month period. And then it takes
forever to get that overpayment back. It got faster a little bit when I found
out I could scan and email them in. It’s not my fault if VAC has a backlog of
earnings loss to calculate… It requires a tremendous amount of planning and if
you don’t have the right financial skills, you run up your line of credit with
the ups and downs.”
2.
Awareness and Engagement
Although
participation in the Rehabilitation Services and Vocational Assistance Program varied,
VAC clients interviewed were all aware of the service offering. Of those
interviewed, most had made use of, or were still involved in, the medical
rehabilitation and/or psychosocial rehabilitation. By contrast, awareness of and participation
in the vocational rehabilitation was notably less common, although some
confusion was evident in terms of whether vocational rehabilitation was offered
through SISIP or VAC.
“I am
a little confused on vocational; whether it is through SISIP or VAC.”
For
most, participation in the medical and psychosocial rehabilitation was driven
by an immediate need for medical and mental attention following discharge and a
clear diagnosis. Most Veterans cited a diagnosis
of PTSD and /or depression, while others had experienced significant physical impairment
that had rendered them unable to effectively integrate into ‘normal’ civilian
life. For them, they understood that vocational
rehabilitation did not apply because of their diminished earning capacity, or
an inability to cope in a workplace setting. A few were not looking to re-enter
the workforce because of their age or tenure in the services.
Some Veterans
had completed their participation in their streams of services, while others
continued to make use of the services and anticipated that they will likely do
so for the remainder of their lives because of their medical conditions.
A few
Veterans commented that they had only learned about vocational rehabilitation
after they were better, and for one, awareness followed a full year without any
type of gainful employment. These Veterans
felt that if they had known of vocational rehabilitation, they would have taken
advantage of it while undergoing medial or psycho-social rehabilitation. Further, they felt that Veterans should be
made aware of their vocational rehabilitation entitlement so it could be
incorporated into goal setting.
3.
Expectations, Effort and Participation
When
asked if the level of participation expected during rehabilitation programs was
reasonable, some mixed opinion was evident.
For most, rehabilitation was always done on their own time and at their
own pace and it was never overwhelming. They
mentioned that a program was developed that forced them to work hard and push
their boundaries, so they were constantly exerting a great deal of effort to
improve. This was especially the case for
physical rehabilitation programs. While some
acknowledged that the amount of effort was often times outside the comfort zone
for many, Veterans recognized that they needed to be challenged often times to
get better. Indeed, many attributed this
’push’ to their improvement. That said, Veterans with this type of positive
attitude all appeared to be driven by a true desire to get better and resume
what they considered a ‘normal life’. Of note, perhaps as a result of having no
formal written case plan, Veterans often reported a lack of clarity on
rehabilitation goals and milestones.
“As
long as I meet my appointment dates, really as long as I participate in the
program, they had no problem with it. This is reasonable expectations… But I
was not given any indication of what was required of me. It would be nice to
know what’s required of you rather than figure out my responsibility on my
own.”
For
others, the rehabilitation plan was perceived to be too aggressive, and this
point of view was more evident for psychosocial rehabilitation. Some reported
having too short timeframe to reach their rehabilitation goals, thus putting
undue pressure on them. It was also believed that such rehabilitation is only effective
if the Veteran is in a mindset to make improvement a personal priority.
The
perceived lack of accountability on the part of Veterans was mentioned by some
as problematic, and opening the door for abuse. It was mentioned that VAC does
not consistently follow-up to ensure that Veterans participate in treatments,
and that there are no consequences of a lack of participation. Further, with
lack of accountability for their actions, it was felt that this would be a time
where Veterans would experience a downward spiral with isolation, addiction and
a lack of accountability all coming to bear.
For
the most part, Veterans generally felt that their goals were aligned with their
needs and expectations at the time they were established, although goal
assessment was considered difficult for those with PTSD or serious emotional or
memory issues. A few Veterans cited that sometimes work-related personal wishes
were not considered in their plan, whereby if a case manager did not feel the
Veteran could perform a job of interest to the Veteran, VAC would not pay for
training.
Despite
a desire by some Veterans for increased accountability from participants to the
Rehabilitation Program, it was mentioned that each person reacts differently to
mental health treatments, and that a psychotherapy session can have immediate
positive outcomes or it can be mentally challenging on the Veteran. As such,
Veterans believed that any progress schedule needs to be aligned to every
individual’s need and remain flexible.
“For
a long time I felt pressured to achieve things that
were way too fast for me. Twelve weeks [to complete the psycho-social
rehabilitation] was not realistic; not when you carry something for 30 years.”
4.
Concern for the Future and Continuity of Care
Veterans were told that some people
say that there are some Veterans who try to extend their participation in the
Case Management Services or Rehabilitation Programs as long as possible for
fear of losing benefits. They were asked how they felt about that situation and
what they believe could be done to minimize this situation.
Most Veterans believed that there will
always be some people who will look to take advantage of the system,
particularly if they have the option to benefit from it financially. That said, they felt strongly that the vast
majority of Veterans do not try to extend participation in Case Management
Services or the Rehabilitation Program.
Rather, it was believed that the vast majority of Veterans want to get
the support needed and the assistance available so they can get better.
“If
there are fakers, I have never heard of someone doing that.”
When considering program extension,
some Veterans expressed a concern for the future and a lack of certainly in
whether or not new medical problems will present themselves later on as a
result of a Veteran’s initial condition.
Understanding that they may never be better, Veterans want to ensure
that they will continue to have the support (both physically and financially)
when and if they need it at some point in the future. Some have seen their condition progress with
age and, at the same time, have had appointments cut back. For them, a concern for the future encourages
them to hang on to their programs and benefits.
“It
is a safeguard that a lot of people need; a reassurance. They feel that if they
don’t have that [benefit], they will be on the street. The fear of not having
that income if they can’t find a job or hold a job. A lot of us have real
difficulty with transition out of military to a civilian job. The transition is
extremely hard. I am still fighting it and I have been out for 10 years.”
“One
of the points I made to my case manager on my last visit was to guarantee me
that the door was open for me in case I needed it. That door is there and I
could call now and they would return my calls in a reasonable amount of time. I
don’t believe there is a timeline for rehabilitation. If there is a timeline, I
would say just reassure [Veterans] that they can re-enter the system.”
At the same time, it was believed by a
few Veterans that isolation or the fear of being isolated once VAC services and
programs ends was another reason why some Veterans may be reluctant to complete
the programs.
“There
is a lack of trust, a fear of being alone. You hear lots of stories where
Veterans come home and are by themselves; there is a fear of being alone.”
That said, a few Veterans felt that
lack of accountability is the greatest culprit in extension of participation
for some. Military people are typically held accountable in everything they do,
from initial entry in the service to their discharge. It was believed that military personnel are
used to structure and accordingly, they expect and want discipline in terms of
clear accountability. It was felt that
once you become a civilian, there is no accountability – no one holds a Veteran
to task. In fact, it was felt that the process is set up in a way that it is
easy to take advantage of. In
particular, a Veteran does not have to prove that they are doing anything, and
this is an important consideration given that it is very easy to get stuck when
you are dealing with psychosocial factors.
That said, a few Veterans felt that while greater accountability is
warranted, the services and programs need to remain flexible to adapt to each
person’s situation.
“It’s
very easy to get stuck [in the system] and say, “screw it” and take the cash.
You don’t have to prove that you are doing anything [towards rehabilitation].
All you have to do is say you are not better and the money is there.
Accountability is the hugest part [of the solution]. In their military job,
military people are held accountable right thru. They are used to that
structure. When they come in to these psycho-social problems, it is easy for
them to take advantage [of the system].”
Finally, just a few felt that once
obvious processes are in place there should be clear repercussions or
restitution for those who abuse the system, so as not to disadvantage the
Veterans who truly need the support.
5.
Facilitators to Participation and Completion of the Rehabilitation
Program
Perhaps the greatest perceived
motivator to participating in the Rehabilitation Program is a desire to get
better and the prospect of an improved lifestyle. Veterans’ expressed need for
‘normalcy’ and re-integration in civilian life were often cited as the greatest
motivator to actively get involved in rehabilitation.
A
number of items were considered important to support Veterans’ rehabilitation
efforts:
Flexibility: In terms of facilitators, Veterans concurred that given the highly
personal nature of rehabilitation plans, flexibility from VAC to allow Veterans
to move at their own pace was key to ensure a successful outcome.
Support/Assistance: Being able to rely on a case manager
to provide relevant and comprehensive information regarding rehabilitation
options was considered important.
Coordination Between Health Professionals: In complex rehabilitation situation
where a number of health professionals are involved (e.g., physiotherapist,
psychologist), having a case manager coordinate communication between health
professionals was considered by a few Veterans as releasing some of the
pressure on them, as well as ensuring better treatment is received.
Finance: Knowing that proper financial support is in place during
rehabilitation helped Veterans focus on their health or vocational goals during
rehabilitation.
A Sense of Security: Perhaps one of the greatest
contributors to feeling comfortable completing the Rehabilitation Program was
the reassurance that assistance remains available to Veterans if they need to
in the future. Veterans believe that people may be more reluctant to complete
the Rehabilitation Program if they feel that VAC support will cease as a
result. Conversely, knowing that VAC services and programs are available during
their lifetime helped Veterans feel a sense of confidence in their future, and
ultimately gain a sense of independence.
6.
Barriers to Participation and Completion of the Rehabilitation
Program
When
asked what might prevent Veterans from participating in or completing rehabilitation
programs, Veterans identified a variety of barriers including:
Finances: A few Veterans commented that the caps for rehabilitation
allotments need to be looked at. One
Veteran explained that VAC puts a maximum dollar amount on the amount of coverage
per visit, with the client paying the difference. In this Veteran’s home province, 95 percent
of all physiotherapists charge a market price that is higher than that covered
by VAC, thus resulting in any physiotherapy being an expense to the Veteran. With limited financial means, the Veteran
considered finances to be a barrier to completing the program.
Distance: Veterans living in rural
areas consistently identified distance as a barrier to completing their
program. For many, travel to appointments
is extensive, inconvenient, sometimes challenging given physical limitations,
and expensive. Unless personally driven
to improve this can result in a diminished likelihood of attending
appointments.
Isolation: Related to the previous
point, a good number of Veterans commented that they live in a rural community
and often have little interaction with others.
For some, living in isolation is not conducive to getting better.
Medical State: A Veteran’s limited
medical condition or unstable mental state were considered barriers to
completing a rehabilitation program.
Access to Medical Appointments: One challenge often experienced by
Veterans is the extensive waiting period for medical appointments. Across provinces, Veterans mentioned a
shortage of physicians, specialists and other health professionals as a
problem, whereby it is difficult to get in to see a doctor. This waiting time for a civilian is often in
sharp contrast to what was experienced in the military. Further, the level of care or interest in
Veterans’ well being was considered at a lower threshold than when Veterans
were in the military, where they had often established familiar relationships
with their doctor.
Lack of a Plan / Case Manager: A few Veterans commented that while
they make regular use of rehabilitation programs through VAC, the fact that
they do not actively have a case manager or a case plan with VAC prevents them
from having a long-term vision for their overall health and recovery. It was felt that a lack of clear plan presents
a clear barrier to improvement and program completion.
Discussion
Analysis of the results of the Client Experiences with VAC
Rehabilitation Program and Case Management Services Qualitative Research Study
reveal that while Veterans value both Case Management Services and VAC’s
Rehabilitation Program, there is a clear opportunity to enhance service
delivery in both regards to secure more active engagement from Veterans and
improve their experience.
Veterans’
level of engagement in the Case Management Services varies significantly
primarily as a result of the perceived strength of the relationship they have
with their case manager and the structured approach to delivering the service.
Veterans
Experiences with Case Management Services
When considering Case Management
Services, findings suggest there is a lack of consistency in the level of
service provided and Veterans are not always clear on what the role of a case
manager includes. Some of the perceived
inconsistency experienced is likely attributed to the mental and physical state
of the individual at the onset of case management and this is an important
consideration in program or case plan development. Indeed, many Veterans begin
their case management experience at a time of severe physical pain, mental
instability, with trepidation and uncertainty for their future. With that in mind, it is not surprising that
Veterans reported often times not recalling full details of discussions or
decisions with their case manager at the early stages.
For the most part, Veterans are satisfied
with the timeliness of case management assignment, however findings show that
there is a need for increased and more complete communication on the full range
of benefits and services available to Veterans, including a better transition
of information from the Canadian Armed Forces to VAC. Veterans are generally
unaware of the full spectrum of benefits and services available to them and are
unsure where such information is easily accessed. Further, many reportedly find
out about VAC benefits through other Veterans or from civilian medical
personnel rather than through their case manager.
While most Veterans have been involved in
their case plan development, findings suggest the process currently lacks
structure and formality. Indeed, results reveal that no formal case plan is
documented for Veterans’ ease of reference, and regular plan follow-up and
review is often times lacking. Veterans consistently spoke of the rigor, structure
and accountability required in military life and have clearly not experienced
that same level of formality in the Case Management Service and Rehabilitation
Program in transitioning to civilian life.
This suggests that increased focus on a more structured or formal plan
could help to align Veterans’ expectations and understanding of the case plan
process.
Veterans’ experiences with case
management vary notably and highlight a number of areas where improvement is
needed. In particular, communication with case managers was often an area of
frustration among Veterans. Most
notably, Veterans expressed a need for printed reference material, direct
access to case managers via telephone or email, and better communication of
service offerings overall. Further, Veterans want a more regimented schedule of
case manager contact for greater certainly, as well as a good understanding of
the steps and milestones involved in Case Management Services.
Veterans’
experience in the Rehabilitation Program was generally positive, notably as
their level of engagement and personal effort is often aligned with the
perceived positive outcome of rehabilitation.
Veterans
Experiences with Rehabilitation Program
Veterans were largely aware of VAC’s
Rehabilitation Services and Vocational Assistance Program, although program
participation varied. Psychosocial and medical rehabilitation are most
prevalent among those interviewed as part of this study, and for the most part,
Veterans exert considerable effort in their rehabilitation programs with a goal
of improving their health. Veterans
typically felt that rehabilitation expectations were reasonable, often times
effectively pushing them beyond their comfort zone. That said, a few believed the rehabilitation
plans were either too aggressive or did not force accountability on the program
participant, which clearly sets the stage for system abuse.
Veterans have enjoyed considerable
positive outcomes as a result of their participation in the Rehabilitation
Program, most notably an increased mobility, an increased ability to interact
with others, greater independence, a more positive outlook on life, and a
better understanding of their own limitations.
In addition, the financial benefits of the programs were instrumental to
most, reducing a significant financial burden placed on the Veteran and his /
her family, providing greater financial security and relieving stress related
to the same.
With few exceptions, Veterans believe
that participating in VAC’s Rehabilitation Program has resulted in a decrease
in the mental and physical barriers they initially face. Those who indicated
that barriers have not decreased, or will never decrease
regardless of the level of rehabilitation they participate in, primarily
attributed their comments to being permanently physically disabled, or coping
with significant mental challenges that appear to them as being insurmountable.
Despite widespread use of some level of
rehabilitation, Veterans face a number of barriers to completing VAC’s
Rehabilitation Programs. These primarily
include distance to treatment, access to appointments, affordability and a lack
of a coordinated plan.
While participation levels in the
Rehabilitation Programs vary, Veterans recognize that some opportunity for
abuse is apparent. Veterans are
discouraged to think that some may abuse a system that is so needed by many.
That said, there is some indication that adding greater levels of
accountability which are more focused on increased communication and closely
monitoring a Veteran’s progress over time, could help to reduce such abuse.
Finally, when asked what would improve
VAC’s Rehabilitation Program, Veterans offered a wide range of suggestions,
including most notably enhanced communications, proactive outreach to Veterans,
and an increased clarity on the full range of benefits and services offered.
Based
on their personal experience, Veterans identified a number of facilitators to
their active participation in the Case Management Services. More specifically,
regular communication, proactive support, accessibility, and personality
attributes were considered paramount in a good working relationship between a
Veteran and their case manager. Conversely, a case manager’s poor personable
skills, being non-responsive, poor knowledge of service offerings, and poor
communications, as well as staff turnover and understaffing were considered as
having a negative impact on service. Many of those facilitators and barriers
were discussed in the last section, with recommendations provided for
improvements.
For the most part, a desire for
re-integrating civilian life and gaining a sense of ‘normalcy’ were considered the
strongest motivator to participating in, and completing, the Rehabilitation
Program. Further, a number of other factors were considered important
facilitators to engage Veterans in the program, including flexible milestones
that are aligned with each Veteran’s situation, support from the case manager,
assistance with coordinating health professionals involved, financial
assistance, and a general sense of security or reassurance that support remains
available even after program completion, should Veterans need it in the future.
Conversely, a number of factors were
identified by Veterans as impeding participation in the Rehabilitation Program.
Most notably, these included limited medical coverage, distance to travel to
take part in the program, lack of a formalized rehabilitation plan or an
assigned case manager, physical and mental isolation combined with unstable
mental state, and wait period to access health care services.
Recommendations
Case Management
The following provides an analysis of key areas of
service that relate to Veteran’s perceived engagement, along with Corporate
Research Associates’ recommendations derived from the analysis of study
findings.
1.
Veterans Relationship with Case Managers
Given that the relationship between Veterans and case
managers is paramount in Veterans’ level of satisfaction and their level of
engagement with Case Management Services, greater acknowledgement and
understanding of the significance of the Veteran and case manager relationship
is needed.
Overall, findings suggest that the relationship with
the case manager and effective communication are paramount in determining how
Veterans view their experience with Case Management Services, as well as being
indicative of their level of engagement. Indeed, those who felt that their case
manager cared and took the time to understand their personal situation, as well
as those who were pleased with the level of contact provided, were generally
satisfied with their experience. To a large extent, they also expressed a
stronger desire to actively participate in their rehabilitation.
2.
Case Management Services Structure
Given the importance of a structured process for
Veterans, and perceived inconsistencies in service delivery, increased structure and rigor are warranted
for VAC’s Case Management Services.
While
Veterans are generally complimentary of the current Case Management Services,
findings suggest there is an opportunity for increased structure within the
service, to better align with Veterans’ expectations following military
service. Implementing a more formal,
structured process, with increased clarity in program / service offerings and
processes, and a more rigorous communication and meeting schedule (including
the involvement of family members/supports), would serve VAC and Veterans
well. In addition, the case manager
should provide the Veteran with a formal documented/written case plan that is
reviewed as needed, such as when the Veteran experiences any change in their
well-being status. More so, it will better align with the regimented approach
that would be expected from someone in the military and offer Veterans a more
comfortable transition to civilian life. In essence, a ‘step-by-step’ guide
would provide Veterans better understanding of the service and provide
reassurance on what to expect.
3.
Case Manager Role
- Characteristics, Knowledge and Skill Set
Given
the importance of the case manager’s ability to build rapport with Veterans in
the level of perceived satisfaction with Case Management Services, VAC should
consider implementing basic service standards that incorporate attributes to
encourage relationship building.
If
such standards are already in place, study findings suggest that they are not
applied equally across the program, and there is merit in reviewing the
standards or how they are applied. Standards should focus on areas of
importance for Veterans, such as timeliness of communication, accessibility,
responsiveness to Veterans’ needs, and personal approach. In addition, VAC
should ensure that all case managers have a clear understanding of what skills
are needed to build or strengthen relationships (e.g., empathy, listening
skills), and are provided access to training to improve in that regard.
4.
Communication
Between Case Managers and Veterans
A
more formalized communication schedule with case managers should be established
and communicated with Veterans.
The study revealed that communication
between a Veteran and case managers is paramount in securing the active
engagement of Veterans. Those who reported close communication with their case
managers consistently expressed a higher degree of satisfaction with Case
Management Services than those who did not. Given that the lack of consistent
and regular communication was identified by Veterans as a key point of
dissatisfaction, a flexible communication schedule should be determined with
each Veteran, as part of their case plan.
In
addition to establishing a structured communications schedule, consideration
should be given to explore various means of contact with Veterans. For example,
the study clearly showed that while the level of contact appears to impact
Veterans’ level of satisfaction with the Case Management Services, the type of
contact is also a key consideration. As such, VAC should explore the
possibility of offering Veterans multiple ways to accommodate in-person
meetings (including the use of online video technology for those in rural or
remote areas), as well as the use of emails and telephone conversations.
Findings
also suggests that reliance on My VAC Account/ Mon dossier ACC is limited and
that some Veterans lack comfort using this tool. Further exploration is
warranted to understand the reasons why this tool appears to be underused. This
could be done through further research to assess whether this is a problem of
awareness, or one of usability.
5.
Awareness of
VAC’s Services and Programs
Summary
information of available programs and services should be made available to
Veterans in print and online formats.
The
study highlighted that Veterans generally lack a complete understanding of the
various benefits and services available to them. Further, they are often
frustrated by the fact that they sometimes find out about benefits and services
well after their immediate need or through other Veteran contacts rather than
through their VAC case manager.
Altogether
this suggests that greater efforts are needed to ensure Veterans are well aware
of the full suite of programs and services they are entitled to, or at least
have reference materials outlining the scope of offerings. While online access to information is valued
by some, findings underscore the need for a printed reference document that can
be easily sourced and reviewed by Veterans and their families / supports.
Having reference documentations does not, however, replace the need for case
managers to counsel Veterans on the most suitable services and benefits for
them, but provides Veterans an opportunity to review all that is available to
them if they wish to do so.
6.
Change in Case
Manager Assignment
The
case manager transition process should be formalized and clearly communicated
to Veterans.
Findings
suggests that consistency in service is a key attribute impacting satisfaction.
A major point of frustration relates to the transition of case managers when
required. Specifically, the process appears unplanned and unstructured to
Veterans, leaving them with the impression that their case ‘is not that
important’ and does not warrant attention when transitioning from one case
manager to another. Formalizing the process may assure Veterans that VAC
recognizes the importance of their situation. The transition process should be
clearly communicated to Veterans, and case-specific information should be
properly transferred to the new case manager.
Rehabilitation Program
Study findings show some variability in Veterans’
experience with their engagement in the Rehabilitation Program, though less so
than with Case Management Services. Most Veterans are focused on the positive
outcomes expected from rehabilitation, and thus adjust their level of
engagement in the Rehabilitation Program accordingly.
1.
Awareness and Participation
Given there is confusion regarding the vocational
rehabilitation program and SISIP, efforts to clarify how the vocational
rehabilitation program differs from SISIP is warranted.
Results show that there is generally good awareness of
the Rehabilitation Program, though participation varies based on individual
needs. It should, however, be noted that there is a great deal of confusion
regarding the vocational rehabilitation stream, which was commonly confused for
the SISIP program. As such, there is merit in considering better explaining the
different streams to Veterans and what each one entails.
In terms of experience, Veterans have enjoyed considerable
positive outcomes as a result of their program participation, which in turn
positively influenced their outlook on the Rehabilitation Program. The more
personal benefit they see, the more engaged they appear in their
rehabilitation.
2.
Accountability
Greater
accountability should be considered for VAC’s Rehabilitation Programs, while
remaining flexible to meet individual needs.
To ensure program completion aligns with
a Veteran’s needs, consideration should be given to the introduction of key
accountability measures for the Rehabilitation Programs. This should include confirmation/reminder of
appointment attendance, provision of accompaniment services, as well as ongoing
follow-up with Veterans on their progress through their case plan. Having a
clearly articulated process with defined expectations or outcomes for the
Veterans (rather than a provision of benefits without any required
accountability), may help to minimize any abuse that may exist, while ensuring
a more heightened focus on Veterans’ health progression. At the same time,
Veterans underscored the importance of the various health professionals and VAC
case managers to remain flexible and accepting of Veterans’ limitations in
progressing through rehabilitation, especially when it involves dealing with
psychological issues. With this in mind, consideration should be given to
discuss milestones or measures with each Veteran, and incorporate those most
relevant to each individual in their case plan, with an understanding that the
case plan objectives, milestones, and progress measures might change over time
based on how the Veteran progresses.
Appendix
A: Recommendations for Survey Items on Future Iterations of the VAC National
Survey
Study results highlight a number of
considerations for future surveys. In
particular, findings suggest survey questions should include closed-ended
question design (versus broad, open-ended questions). In addition, there is merit in including
measurement of key indicators that assess performance of factors that could
impact a Veteran’s successful program outcome, such as whether or not a
Veteran:
·
has a full understanding of available benefits / services;
·
received a printed copy of their case plan (including a schedule
for its review);
·
received a schedule of meetings / contact with their case manager;
·
has a case manager assigned to them;
·
has had in-person contact with their case manager; and
Consideration should also be given to evaluate
Veterans’ perceptions of key case manager attributes (empathy, responsive,
caring, understanding, etc.).
Appendix
B: Veteran Participants’ Recommendations for the Rehabilitation Services and
Vocational Assistance Program
Enhanced communication with Veterans: Veterans identified a variety of
ways in which communication could be improved with Veterans. These included:
o
More timely response to queries
o
Direct / better access to a case manager
o
Email access to a case manager More simplistic written
communication
o
Monthly or quarterly newsletters
o
Streamlined documentation; more pointed questions; closed-ended
versus ‘how has this impacted your life’
o
Assistance when filling out forms (some do not have mental
capacity to do so)
o
More communication between VAC and the military
o
Share information on what resources are available in the community
o
Improved communications between provinces and VAC (especially
related to mental health services
Better communication of eligible benefits and services: Veterans expressed a need for a
greater understanding of what benefits and services are available from VAC, and
they would like to have this information at discharge. A complete, but simplistic description of
available benefits is needed.
Suggestions included:
o
Clearly outline what benefits are available
o
Ensure information is immediate at discharge
o
Write communications at a lower grade level (given challenging
mental states)
o
Don’t send people online (difficult to navigate)
o
Better communication of VAC benefits prior to discharge (i.e.
while still in-service)
o
Web page of all treatments / benefits available and examples (but
make it a secondary information source for those who are web savvy)
Improved case manager relations: Having increased contact with case
managers was considered essential, and this contact is desired in multiple
ways, with rigor?:
o
Proactive versus reactive contact with Veterans
o
If case manager has not heard from Veteran, initiate an in-person
visit (important especially if in isolation)
o
Focus on rural outreach
o
Clearly outline a schedule of contacts
o
Remind case managers of the Veterans’ Charter
o
Build a connection with clients (reach out regularly to Veterans)
o
Hire more staff / reduce turnover
o
Enhanced training specific to dealing with Veterans for case
managers
o
Better outreach to Veterans and their families
o
More one-on-one with case managers
o
Include Veterans and their supports in meetings with case
managers.
o
Advise when case manager changes
Increased Accountability: Veterans would like to have a clear
understanding of the Rehabilitation program process, requirements for Veterans
and how they will be held accountable:
o
Educate Veterans of expectations / requirements / process
o
Be more accountable
o
Clearly outline ‘rules of the game’ (there was a perception that
currently, there are rules that have to be followed, but those rules or
processes are hidden or known only by VAC)
Benefit Payments: Veterans would like better coverage
for specific benefits and a quicker payment of benefits given that many
Veterans face significant financial hardship and are dependent on financial
benefits that are often slow to arrive:
o
More timely distribution of benefits:
o
Enhanced transportation services
o
Ensure that coverage for physio reflects market conditions
Appendix
C: Political Neutrality Statement
Political
Neutrality Certification
I
hereby certify as a Representative of Corporate Research Associates Inc. that
the deliverables fully comply with the Government of Canada political
neutrality requirements outlined in the Directive on the Management of
Communications. Specifically, the deliverables do not include
information on electoral voting intentions, political party preferences,
standings with the electorate, or ratings of the performance of a political
party or its leaders.
Signed 
Margaret Brigley, President & COO | Corporate Research
Associates
Date: April 24, 2019
Appendix
D: Recruitment Screener
NAME: _________________________ Community:
_________________________
TEL. # (H): _______________________ ALT TEL/ #:
__________________________
Telephone Interviews:
English: 1 2 3 4 5 6 7 8 9 10
11 12 13 14 15
16 17 18
19 20 21
22 23 24 25
26
French: 27
28 29 30
31 32
Interviews:
|
<DATE
RANGE> |
||||
|
Refer to interviewing schedule |
|
|
|
|
|
Specification Summary |
|
|
·
Between 25-32 interviews in total: 20-26 English interviews and 5-6 French interviews o
Up to 32 interviews with two audiences: §
Current or past participants of Rehabilitation Program: Min 10
interviews §
Current or past recipients of Case Management Services: Min 10 interviews |
·
Client-provided sample of VAC clients who participated in the VAC
National Survey in 2017 ·
Mix of age and gender, where possible ·
Interview length: 1 hour ·
Incentive: $75 |
Introduction
May I speak
with ___? Hello, my name is____ and I am
with Corporate Research Associates, a market research company. I am calling today on behalf of the
Government of Canada, specifically Veterans Affairs Canada, or VAC.
Would you prefer that
I continue in English or in French? Préférez-vous
continuer en français ou en anglais? [IF
FRENCH, CONTINUE IN FRENCH OR ARRANGE CALL BACK WITH FRENCH INTERVIEWER: Nous
vous rappellerons pour mener cette entrevue de recherche en français. Merci. Au
revoir.]
You participated in the VAC National
Survey in 2017 and you indicated at that time that you would like to be
contacted for further VAC-related research.
We are now conducting a series of telephone interviews with VAC clients
and are looking for people to take part. The purpose is to obtain feedback from
VAC clients regarding the Case
Management Services and the Rehabilitation Services and Vocational Assistance
Program based on your own experiences of participating in these. The
research findings will be used by VAC to improve service delivery and program
management.
The interview will last one hour and will
be conducted within the next two weeks. Those who take part will receive $75 in
appreciation for their time. Are
you available and interested in participating in this study? IF YES, CONTINUE – IF NO, THANK &
TERMINATE
To explore
various aspects of the VAC programs and services under review, we are looking
to include a diversity of people in the study. May I ask you a few questions to
see if you are the type of participant we are looking for? This should take about 4 or 5 minutes. The
information you provide will remain completely anonymous and confidential and
you are free to opt out at any time. The information collected will be used for
research purposes only and handled according the Privacy Act of Canada. Also,
please note that your participation in this research will not affect your
relationship with VAC or your eligibility to or current receipt of benefits.
IF STUDY NEEDS TO BE VALIDATED: You can
contact [Dr. Lisa Garland Baird] from Veterans Affairs Canada at [902-370-4981]
or [Lisa.garlandbaird@canada.ca] or call the VAC National Contact Centre
Network (NCCN) at 1-866-522-2122 to verify the validity of the study. SCHEDULE A CALL BACK BEFORE ENDING THE
CALL
THANK & TERMINATE WHERE REQUIRED IN
THE SCREENER: Unfortunately, we will not be able to include you in this study.
We already have enough participants who have a similar profile to yours. Thank
you for your time today.
To begin:
1.
Are you currently
involved in any of the following VAC programs?
Yes No Unsure
a) Rehabilitation Services and Vocational Assistance Program (not
SISIP)............ 1............ 2.............. 8
b) Case Management Services.......................................................................... 1............ 2.............. 8
INTERVIEWER INSTRUCTIONS – DEFINE EACH PROGRAM IF NEEDED:
Rehabilitation Services and Vocational Assistance
Program: The purpose of the rehabilitation program is to
ensure that Veterans improve their health to the fullest extent possible and
adjust to life at home, in their community or at work. It includes medical
rehabilitation, psycho-social rehabilitation, and vocational rehabilitation of
a person.
Case Management Services: Case Management Services
are provided by VAC to assist Veterans and their family to reach appropriate
goals towards independence and well-being. VAC Case Management services enable
clients with complex needs, and their families, to achieve mutually agreed upon
goals through a collaborative, organized and dynamic process, coordinated by
the VAC Case Manager.
2. [ASK IF YES AT Q1A OR Q1B] How long have
you been involved in the [READ]?
a)
Rehabilitation
Services and Vocational Assistance Program:
_____________ (months / years)
b)
Case
Management Services: ___________________ (months / years)
3.
Did you
participate in any of the following VAC programs in the past?
a) [DO NOT
MENTION IF “YES” AT Q1A]
Rehabilitation Services and Vocational
Assistance Program................... 1.......... 2......... 8
b) [DO NOT
MENTION IF “YES” AT Q1B]
Case Management Services................................................................ 1.......... 2......... 8
IF “NO” OR “UNSURE” AT BOTH Q1A AND Q1B AND
BOTH Q3A AND Q3B (HAVE NEVER PARTICIPATED TO EITHER PROGRAMS), THANK &
TERMINATE
FOR OTHERS, CONSIDER QUOTAS BY PROGRAM AS
SPECIFIED IN THE SUMMARY
4. When did you finish or stop receiving
services from the [READ]?
a) [ASK IF “YES”
AT Q3A] Rehabilitation
Services and Vocational Assistance Program: -------------------
b) [ASK IF “YES”
AT Q3B] Case Management
Services: __________________
5. [ASK IF "YES” TO REHABILITATION
PROGRAM IN EITHER Q1A OR Q3A] What streams of the VAC Rehabilitation
Services and Vocational Assistance Program do you currently take part in or
have you experienced in the past? Would it be [READ]? MULTIPLE
RESPONSES ALLOWED
Current Past Unsure
a) Vocational............................... 1............ 2............ 8
b) Medical................................... 1............ 2............ 8
c) Psycho-social........................... 1............ 2............ 8
6. Which of the following age categories
includes your own age? Please stop me when I reach your age group. Are you:
Under 18........................................ 1 Thank
and Terminate
18 to 29......................................... 2
30 to 39......................................... 3
40 to 49......................................... 4
50 to 59......................................... 5 Aim
for a mix if possible
60 to 69......................................... 6
70 to 79 ........................................ 7
80 to 89 ........................................ 8
90 and over................................... 9
[VOLUNTEERED] Refused............... 97
7. [ASK IF YES TO REHABILITATION PROGRAM IN
EITHER Q1A OR Q3A] How would you rate the VAC Rehabilitation Services and Vocational Assistance Program
based on your overall experience? Are you generally [READ]?
Completely
satisfied....................... 1
Somewhat satisfied........................ 2 Aim for a mix
if possible
Somewhat dissatisfied................... 3
Completely dissatisfied.................. 4
8. [ASK IF YES TO CASE MANAGEMENT SERVICES IN
EITHER Q1B OR Q3B] How would you rate the VAC Case Management
Services based on your overall experience? Are you generally [READ]?
Completely
satisfied....................... 1
Somewhat satisfied........................ 2 Aim for a mix
if possible
Somewhat dissatisfied................... 3
Completely dissatisfied.................. 4
INVITATION
I would like to invite you to take part in
a telephone interview. The interview will be conducted at a time that best
suits your schedule in the next two weeks. The interview will last one hour and
you will be offered $75 in appreciation for your time. Note that the
information you share as part of this research will not affect your
relationship with VAC or your eligibility to or current receipt of benefits.
The research findings will be used by VAC for the only purpose of improving
service delivery and program management. VAC will not share information related
to this study with other organizations.
9.
Are you
interested in taking part?
Yes............................................ 1
No ............................................ 2
Thank and Terminate
10. In which language would you like to
conduct the interview, English or French?
English........................................... 1
French........................................... 2 SCHEDULE ONLY WITH FRENCH MODERATOR
11. The interview discussion will be audio
recorded for research purposes only. The recordings will be used by researchers
at Corporate Research Associates and at VAC to assist with the analysis of
research findings. To protect your identity, the moderator who will conduct the
interview will use a pseudonym to identify you during the discussion rather
than using your real name. Please also be assured your comments and responses
are anonymous as part of the final reports.
Knowing this, are you comfortable with the
discussion being audio recorded?
Yes............................................ 1
No............................................. 2
MARK ACCORDINGLY ON RECRUITING
FILE
12. And are you comfortable with the
recordings being shared with VAC?
Yes............................................ 1
No............................................. 2
MARK ACCORDINGLY ON RECRUITING
FILE
INTERVIEWER
INSTRUCTIONS: Respondents
can also decide if they consent to recording and/or sharing the recording with
VAC on the day of the interview.
ADDITIONAL
INFORMATION ON THE SAFEGUARDING OF PERSONAL DATA – PROVIDE AS NEEDED: Personal data will be anonymized and destroyed in
accordance with government security policy following completion of the Report
with VAC guidance and approval.
Note that the
study report, once finalized, will be made available to the public in 6 months
after completion, through Library and Archives Canada. As mentioned earlier,
your name will not be included in this report.
Interviews will be conducted from
<DATE>. What time and date would be most convenient?
_____________________________________ CHECK
SCHEDULE/RECORD TIME / DATE
As mentioned,
we will be pleased to provide everyone who participates with $75, in the form of a cheque. Please note it takes approximately 2-3 weeks
following your interview to receive an incentive by cheque. Could I have the mailing address where you
would like the cheque mailed after your interview?
Mailing address:________________________________________________________________
City:
________________________________________________________________________
Province:
____________________________________Postal Code: _____________________
And please
confirm the spelling of your name: _______________________________________
READ TO ALL
We are
conducting interviews with a limited number of individuals, so the success of
the study will be affected by no shows. Once you’ve decided to take part please
make every effort to do so. If you are unable to take part in the study, please
call_____ (collect) at ________as soon as possible so a replacement may be
found.
Thank you for
your interest in our study. We look
forward to hearing your thoughts and opinions!
ATTENTION
RECRUITERS
1.
Recruit 25-32 interviews (SEE QUOTAS)
2.
Do not put names on profile sheet unless
you have a firm commitment.
Confirming with participants
1.
Confirm attendance with each participant
at the beginning of the day prior to the day of the interview
2.
Verify date and time
Appendix
E: Interview Protocol
Veterans
Affairs Canada Client Survey
Pseudonym: _________________________________________________________
Case Management Services [ ] Rehabilitation Program [ ]
Province: ____________________________________________
Date/Time of Interview: ___________________________________________
ü Explore
clients’ perceived experiences with their engagement in the Rehabilitation
Program and/or Case Management Services;
ü Identify the
facilitators and barriers to clients’ participation in the Rehabilitation Program
and/or Case Management Services;
ü Identify the
facilitators and barriers to clients’ completion of the Rehabilitation Program
and/or Case Management Services;
ü Make
recommendations for survey items on future iterations of the VAC National
Survey; and
ü Make
recommendations for future research to support the development, management, and
improvement of programs and services for Veterans and their families.
·
Thank you for
taking the time to help us with our study.
Our discussion should take about one hour.
·
The purpose is
to obtain feedback from VAC clients regarding the Case Management Services and
the Rehabilitation Services and Vocational Assistance Program based on your own
experiences of participating in these. The research findings will be used by
VAC to improve service delivery and program management.
·
The
information you provide today will remain completely anonymous and confidential
and you are free to opt out at any time. The information collected will be used
for research purposes only and handled according the Privacy Act of Canada.
Also, please note that your participation in this research will not affect your
relationship with VAC or your eligibility to or current receipt of benefits.
·
With your
permission, our interview discussion today will be audio recorded for research
purposes only. The recordings will be used by researchers at Corporate Research
Associates and at VAC to assist with the analysis of research findings. To
protect your identity, the moderator who will conduct the interview will use a
pseudonym to identify you during the discussion rather than using your real
name. Please also be assured your comments and responses are anonymous as part
of the final reports.
·
Are you ok with
our conversation being recorded? At the
end of the discussion, I will ask for your permission to share the recordings
with VAC so you can take that decision based on the information you will share
during our discussion.
·
Any questions
before we begin?
I would like
to begin by talking about your experience with the Case Management Services. As
you may know, a case manager helps clients set goals and find the services they
need to overcome challenges in their life. Some examples include: a plan to
achieve goals, referrals to services needed, and ongoing support in difficult
situations.
·
Do you currently or did you in the past have a VAC case manager who
works/worked with you to obtain services?
IF YES, ASK THE FOLLOWING QUESTIONS:
·
Were you assigned a case manager in a reasonable amount of time?
- How long did you have to wait to have a case manager assigned to you?
- IF UNREASONABLE TIME: What
would have been a more reasonable amount of time? Why do you feel this
amount of time would be more reasonable?
·
In general, how effective was your working relationship with your case
manager?
- What, if anything, worked well?
- And what proved problematic, if anything?
·
Were you involved in the development of your case plan? Why/Why not?
- If so, how were you involved?
·
Were you given the opportunity to involve your family and other supporters
in the development of your case plan?
- If so, how involved were they? What role did they play?
- How could this have been improved?
·
How satisfied are you with your case plan?
·
Were the goals in your case plan reflective of your needs? If no, why not?
- Were your goals relevant to helping you? Why/why not?
- What could have been done to ensure that these goals are more
reflective of your priorities?
·
To what extent do you feel that you had regular contact with your case
manager to discuss your progress?
- How often were you in contact with your case manager?
- How do you feel about this level of contact?
- IF TOO MUCH/NOT ENOUGH: What
would be a better level of contact?
- How do you feel about the timeliness of response to your call from
your case manager?
§ IF NOT SATISFIED: How could this be
improved?
·
To what extent do you feel that working with your case manager has helped
you stay better informed on how to access VAC programs and benefits that you
need? Why do you say that?
·
Has your case manager told you about services and supports in your
community that helped you?
Now let’s
discuss the VAC Rehabilitation Services and Vocational Assistance Program more
specifically. The VAC Rehabilitation Services and Vocational Assistance program
provides services such as medical and psycho-social rehabilitation to aid in Veteran’s
re-establishment in life after service. So for this
part of the discussion I will ask you to think of the VAC Rehabilitation
program and NOT SISIP programs.
·
Were you aware of the VAC Rehabilitation Services and Vocational Assistance
Program?
·
IF SO: What stream
are you currently or have you in the past participated in, if any: medical
rehabilitation; psychosocial rehabilitation; or vocational rehabilitation?
·
Did you complete your participation in any of the streams or are you in
currently using these services?
- IF COMPLETED: When was
your participation completed?
- IF IN PROGRESS: When did
you begin the program?
·
Do you feel that the level of participation that was expected of you was
reasonable? Why/why not?
·
How much effort do you feel you had to put in to follow your rehabilitation
plan?
·
To what extent to you feel that your participation in the program has
helped improve your quality of life?
- IF IMPROVED: What has
improved? How has it improved?
- How else, if at all, has your participation in the program been
beneficial to you?
·
Since participating in Rehabilitation Services and Vocational Assistance
Program do you feel that barriers you faced have decreased? In this context,
barriers refer to a temporary or permanent physical of mental health problem that
limits or prevents reasonable performance of your role in the workplace, home
or community.
- IF NO: Why do
you feel barriers you face have not decreased? Have any barriers worsened
since you started the Rehabilitation program? Which ones? What areas of your
life was affected: home, work, community? Why has the situation
deteriorated?
- IF YES: What
improved? In what area of your life – home, work, community? And how have
things improved?
·
To what extent has the Rehabilitation and Vocational Assistance program
helped you return to work or to your daily activities?
- Are there any barriers to completing the program?
- PROBE IF NOT MENTIONED: Some
people say that there are some Veterans who try to extend their
participation in the case management or rehabilitation programs as long as
possible for fear of losing benefits. What do you think of that situation?
What could be done to minimize this situation?
·
How has your participation to the Rehabilitation Services and Vocational
Assistance program impacted your family or supporters who have assisted with
your progress?
- How has it benefited them if at all?
·
Based on your experience, how satisfied are you with the Rehabilitation
Services and Vocational Assistance program?
·
What recommendations do you have, if any, to improve the Rehabilitation
Services and Vocational Assistance Program, and ensure that it helps Veterans
improve at home, in the community and at work?
That’s all my
questions. Thank you for your time today. As mentioned earlier, we would like
to share the recording from this interview with Veterans Affairs Canada, for
research purposes only. Are you comfortable with us sharing the recording with
VAC? IF NO, ASSURE PARTICIPANTS THAT RECORDINGS WILL NOT BE PROVIDED TO
VAC
On behalf of
Veterans Affairs Canada and Corporate Research Associates, thank you for your
participation.
Appendix
F: Background Documents
The
following notes were provided by Veterans Affairs Canada to inform the
development of the discussion guide.
Case Management
The
results from the case management section of the VAC National Survey 2017
indicated that only 53% of clients agreed or strongly agreed that the client
was given the opportunity to involve their family in developing their case
plans
·
The role and involvement of family members/social supports appears
to be valued by VAC clients. Examining
the reasons why clients reported that they were not given the opportunity to
include their family members/social supports in case planning is important as
VAC has led initiatives to encourage the engagement of families in case
planning.
Results
from the VAC National Survey as well as reports from the Veterans Ombudsman
Office indicated that many clients are not satisfied with the amount of time they spend with their Case Manager. Additionally,
comments in the VAC National Survey the indicated that some clients want to
engage and be engaged by their Case Manager more often. Exploring this aspect
of the client’s experiences with Case Management may indicate a gap that needs
to be addressed by CM services.
Rehabilitation and Vocational Assistance
The
VAC National Survey indicated that the clients were very critical of
Rehabilitation Services and Vocational Assistance. Between 20% and 29% of
clients did not feel it improved their situation (especially their roles at
work and in their community).
Considering that the purpose of the Rehab Program and Vocational
Assistance is to improve the overall health and well-being of Veterans and their
families, this finding clearly indicates a significant problem with the
program/services.
·
The VAC National Survey did not clearly delineate the differences
between the Rehabilitation Program and the Vocational Rehabilitation Program
which is provided by a third party. Clarifying the differences between the
Rehabilitation Program and the Vocational Rehabilitation Program for clients
participating in the qualitative study is significantly important as may help
to capture their experiences with VAC and with the third-party provider separately.
The
expectations of VAC and the expectations of the clients in Rehab are arguably
not aligned. In discussion with the Rehab program managers, they believe that
the clients in Rehab may not fully understand that the purpose and goal of the
Rehab program is for them to improve their health to the point that they can
disengage from the program.
Additionally, results from the VAC National Survey indicated that nearly
30% of clients did not think they engaged in enough discussions with their Case
Manager on their progress and achievements. There were also some comments in
the survey which indicated that clients were unsure/uncertain about their goals
for the Rehab Program.
Rehab
program managers speculate that the financial and health care benefits that
many clients receive during that Rehabilitation Program may result in some
clients remaining longer in the program than necessary. The benefits are arguably an incentive to
remain in Rehab because once the clients finish the program, they lose these
benefits. The loss of these benefits may
mean added health care expenses and significant losses in the client’s overall
income following program completion. Concern with the role and significance of
financial and health care benefits for clients in Rehabilitation was flagged as
an important issue to explore during the consultations with the Rehab program
manager and Audit and Evaluation at VAC.
Rehab
program managers also speculated that there may be notable differences in how
certain groups of clients move through and finish the rehab program. The
program managers commented that the clients with more predominant mental health
conditions may have a tendency to remain in the Rehab Program longer than other
clients with predominantly physical health problems. The impact of certain
health conditions on a clients’ experience in the program is an important issue
to consider in the design of the qualitative research project according to the
Program Managers.