Veterans Affairs Canada’s Client-Centered Delivery of Mental Health Services to Clients living with
Veteran’s Affairs Canada
Canada

The Problem

Veterans Affairs Canada’s Client-Centered Delivery of Mental Health Services to Clients living with Operational Stress Injuries, Using a Shared Governance Approach

Solution and Key Benefits

 What is the initiative about? (the solution)
In recent years, Canadian Forces (CF) have been increasingly committed to international and multi-lateral military operations as well as to peacekeeping missions. The nature and incidence of multiple and longer deployments for Canadian Forces (CF) members and the continuous exposure of Royal Canadian Mounted Police (RCMP) members to modern-day threats and conflicts, led to an increasing prevalence of operational stress injuries (OSIs) related to military service, including post traumatic stress disorder (PTSD).

In order to address this increasing prevalence of OSIs, Veterans Affairs Canada (VAC) was proactive in the development of its National Mental Health Strategy. This strategy included a unique service delivery approach aimed at building a comprehensive OSI network. This network is founded on five key elements: client-centred programs and services, accessibility and continuity of care, seamless and integrated service delivery throughout the OSI network; continuous quality improvement and shared governance.

VAC has successfully built its mental health care capacity at a national level through the creation of an innovative network involving multiple partnerships. These partnerships include those among three federal departments, four provincial health authorities, a vast array of public and private community level service providers, universities and research centres. Today, this OSI network provides an unprecedented, unique portal for the client with an OSI and his or her family to access a continuum of comprehensive specialized mental healthcare services and programs across the country.

With this initiative, VAC has successfully improved specialized mental health care service delivery in Canada and positively impacted Veterans’ and CF member’s quality of life. Transition from military to civilian life has been eased and availability, accessibility, continuity and appropriateness of care have been enhanced on a national scale. This cutting-edge OSI expertise has contributed to the advancement of OSI-related knowledge both in Canada and internationally.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
2001:
-Development of Veterans Affairs Canada (VAC) Initiative to address the mental health needs of its clients.
-Creation of Ste. Anne Centre (SAC) as a regional Operational Stress Injury (OSI) clinic based at Ste. Anne’s Hospital (the only remaining VAC long term health care facility in Canada entirely dedicated to Veterans).
-Memorandum of Understanding between VAC and the Department of National Defence (DND) to initiate a pilot project aimed at providing mental health services to eligible clients at SAC and the Operational Trauma Stress Support Centres (OTSSCs) (DND facilities at Equimalt, Edmonton, Ottawa, Valcartier and Halifax).

2002:
-Joint DND/VAC Mental Health Advisory Strategy launched to provide comprehensive mental health assessment and treatment services through a network of excellence supported by research, educational forums and a continuing education program.

2002-2006:
-Partnership established between VAC and Provincial Regional Health Authorities to create four new OSI clinics (in Ontario, Quebec, Alberta and Manitoba) based on the SAC model.
-Establishment of innovative service delivery initiatives including distribution of advanced training programs and introduction of mental health subject matter experts at all levels of VAC.

2005:
-SAC takes on the role of national clinical leader in the field of mental health. SAC then adopted a tripartite structure fully reflecting its new role:
-A regional mental health clinic;
-A National Mental Health Clinical Centre of Expertise to promote care through research, education and the development of programs;
-A Network Development and Coordination Division to develop a network of specialized clinics in Canada.

2006:
-Development of VAC’s Mental Health Strategy to consolidate efforts in delivering a continuum of mental health services, building capacity for the delivery of these services, leadership and partnership.
-Establishment of Mental Health Policy Directorate within the Head Office of VAC to co-ordinate the implementation of VAC’s Mental Health Strategy.
-Memorandum of understanding between VAC and DND creating a Mental Health Partnership to build a combined VAC/DND OSI network accessible to all eligible Veterans, Canadian Forces and RCMP members across the country, regardless of where they live in Canada.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
In recent years, Canada has increasingly committed its armed forces to international and multi-lateral operations to protect its national interests, combat global terrorism and carry out peacekeeping missions. The nature and incidence of multiple and longer deployments for Canadian Forces (CF) members and the continuous exposure of Royal Canadian Mounted Police (RCMP) members to modern-day threats and conflicts, led to an increasing prevalence of operational stress injuries (OSIs). An OSI is “...any persistent psychological difficulty resulting from operational duties performed while serving...” and includes psychiatric conditions such as Generalized Anxiety Disorder, Major Depression and Post Traumatic Stress Disorder (PTSD). Over the past five years, the number of clients pensioned for a psychiatric condition at Veterans Affairs Canada (VAC) grew by almost 400%; 68% of these clients were diagnosed with PTSD.

Several reports such as those from the Standing Committee On National Defence and Veterans Affairs (House of Commons) and the Standing Senate Committee on Social Affairs, Science and Technology (Kirby Report - Out of the Shadows At Last), have underlined Canada’s lack of preparation in addressing the urgent needs of Canadians with mental health conditions. Missing components to an effective response cited were:

-a national mental health care vision and strategy
-mental health service delivery infrastructures
-accessibility of mental health professionals such as psychiatrists, psychologists, mental health nurses and social workers
-availability of specialized mental health programs such as group therapy, psycho-education, residential care and short-term hospitalization and chronic pain management clinics
-specialized expertise in the domain of OSIs.

VAC decided to meet this challenge by developing a national client-centered mental health strategy which addressed issues such as the recognition of OSI as a mental health condition, nationwide accessibility of services, continuity of care, client rehabilitation and family support. The strategy involved the following:

-the development of strong policies and business processes to support mental health care delivery based on client needs using a case management approach
-the development of clinical expertise through the creation of Sainte Anne’s Centre (SAC)
-the establishment of an integrated national network of OSI clinics based on the SAC model
-the collaboration with mental health professionals to conduct research and promote innovative approaches and best practices in the assessment and treatment of OSIs
-the expansion of service delivery capacity nationwide through partnerships with community mental health service providers

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
VAC assumed a leadership role in developing a national mental health vision specific to OSIs in collaboration with the Department of National Defence (DND), the other major service provider in this field. In exploring the issues together, several priorities were identified. These include the creation of a joint network of OSI clinics /OTSSC programs collaborative research initiatives, education forums aimed at standardizing clinical practices and ongoing training programs. Based on these premises, VAC developed a national Mental Health Strategy with three key objectives:

The strategy’s main purpose is to build capacity across the country in order to provide specialized care to clients suffering from OSIs to act as a complement to existing health services in the community. These services would include established mental health programs in the areas of health promotion, early intervention, treatment, rehabilitation and follow-up.

The second purpose is to improve service delivery quality by maximizing synergies through the use of common protocols, shared best practices and standardized performance indicators throughout an integrated network of OSI clinics and local community service providers.

The third purpose is to enhance knowledge of VAC staff, OSI mental health professionals and contracted service providers through research and ongoing training in the specialized area of OSIs.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The VAC National Mental Health Strategy is rooted in the following five principles:


1)Client-Centered:

Recognizing the uniqueness of each individual and the complexity of an OSI, VAC developed an interdisciplinary approach and case management model designed to address both the mental health and social needs of clients and support their transition into civilian life.

This client focus was further maintained through consultative forums and client focus groups conducted prior to the establishment of SAC. This strong client-centred experience led SAC to develop an expertise in understanding the complex nature of OSIs, which was consolidated by systematic client satisfaction surveys to evaluate its clinical programs. A survey process based on a sound methodology and established quality domains allowed a 75% client participation rate. This provided invaluable information to guide decisions about the future of the network

Such achievements led VAC to recognize the clinical leadership of SAC by creating the National Clinical Centre of Expertise, mandated to develop and promote best practices through ongoing education, collaborative research with universities and expert consultative services.


2)Accessibility and Continuity of Care:

Capitalizing on SAC’s clinical programs, VAC duplicated the SAC model by creating an OSI clinic network that met both clinical effectiveness and operational efficiency. In this context, agreements were reached with Provincial Health Authorities to build a geographically complementary network to that of DND. Today, the VAC network comprises five specialized clinics.

To further improve accessibility (including in remote areas) partnerships were created with local community services, peer support groups, professional associations and the piloting of telemental health services. Beyond enhanced accessibility, these partnerships also provide continuity of care from the acute phase to eventual follow up.


3)Seamless Transition:

VAC’s service delivery philosophy is founded on a seamless continuum of care approach. Its key innovation is the Transition Interview performed by VAC Transition Officers to identify early any impediments to successful transition towards civilian life. A comprehensive assessment by Area Counsellors, followed by referrals to appropriate services in the network completes this process.

The close coordination between VAC District Offices, regional clinics and community service providers is another strength of this approach. This coordination is provided by Mental Health and Rehabilitation Officers at regional and national levels.


4)Continuous Quality Improvement:

SAC was instrumental in defining the quality domains and indicators needed to evaluate clinical program outcomes. Several performance indicators were developed in six quality domains (accessibility, acceptability, appropriateness, continuity, safety and effectiveness). These are now shared by all clinics in the OSI network and at the DND OTSSC programs. This framework is consistent with the VAC Quality Management Program.


5)Shared Governance:

VAC’s governance sharing approach involved the establishment of a consistent and effective continuum of care across federal departments (VAC, DND, RCMP), various provincial health jurisdictions, community partners, public and private sectors. This was an innovative way for a federal department to build capacity while avoiding the duplication of existing services. This bottom-up vision of mental health service delivery is client driven and rooted in a response to their complex needs.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The changes resulting from this strategy are, to date, many and measurable. Our quality management framework is driven by a balanced scorecard approach.


1)Client Perspective:

-Service utilization at VAC OSI clinics has grown from 8 clients in 2001 to almost 1,000 to date.

-Accessibility of service has been improved through the establishment of a joint network of ten OSI clinics/OTSSC programs and 900 service providers in the community. Today, the VAC-DND-RCMP mental health partnership is a unique, integrated national portal in Canada towards standardized, high quality service and care delivery for all admissible VAC, Canadian Forces and RCMP clients, wherever they live in Canada.

-Availability of service has been significantly enhanced. As the OSI network continues its expansion with 3 new clinics in the next 3 years, close to 80% of clients should have access to a mental health professional within 150 kilometres of their home.

-The latest results of the annual client satisfaction survey, administered throughout the OSI clinic network, indicated that 84.4% of clients are satisfied with the care and services received.


2)Core Clinical Programs:

-Clients are offered specialized mental health services based on best practices as promoted by VAC’s National Clinical Center of Expertise.

-In order to evaluate clinical effectiveness, a National Standardized Assessment Program has been created and is now ready for implementation nationwide. This will position VAC internationally with regards to ongoing data collection, clinical program evaluation and research.


3)Qualified Mental Health Human Resources:

-To date, over 2,000 professionals have received training and educational sessions from the SAC team, including more than 35 coordinators and 75 volunteers from the “Operational Stress Injury Social Support” (OSISS) peer support program.

-A national symposium on OSIs was held in Montreal in 2003 with over 300 participants. A second national symposium is planned for May 2007. A projected 500 participants will have the opportunity to learn from an international panel of experts.

-VAC has actively participated in two Best Practice International Forums on PTSD in 2003 and 2007 thus contributing to the exchange of knowledge in the field of OSIs worldwide.


4)Research-Based Knowledge:

-VAC is actively involved in ongoing research in 5 domains. 9 research articles have been submitted for peer review. Two have already been published.

-A National Standardized Assessment Program will provide baseline and longitudinal data that will help define future research questions.

-VAC research findings in the area of OSIs are shared with the international community through a participation in international symposia (for example, through annual presentations at the International Society for Traumatic Stress).

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The VAC Mental Health Strategy is sustainable and transferable from a variety of perspectives.


1)Sustainability from the Client Perspective:

Sustainability is ensured as it is rooted in client need. Consultations with clients, client focus groups as well as clinical assessments conducted by mental health professionals have identified the unique and complex needs of this client group. The quality improvement framework which includes performance indicators and client satisfaction surveys has confirmed that the mental health strategy is meeting client needs. The framework also identifies unmet client needs and directs future quality improvement initiatives.


2)Sustainability from the Partnership Perspective:

The VAC Mental Health Strategy capitalizes on synergies among federal, provincial, local, public and private networks of service providers. The goal is to increase capacity by building on existing mental health services thus minimizing duplication, maximizing accessibility to appropriate mental health programs and providing the availability of specialized human mental health resources.


3)Transferability of Knowledge within the OSI Community:

VAC has become a Canadian leader in the development of specialized mental health care and service delivery. In doing so, VAC is now transferring its knowledge and expertise to the broader community. This transfer of knowledge has been accomplished through the creation of a National Clinical Centre of Expertise. The role of this centre is to contribute to the development and promotion of best practices through ongoing education, collaborative research activities with university centres and through the provision of expert consultative services. Such bridges can also be found at the provincial level given that all OSI clinics within the VAC network are affiliated with at least one university. Through research and training, transferability therefore goes far beyond the initial target of VAC, DND and RCMP clients.

VAC has also established international partnerships through its active role in the Seniors International Forum comprised of senior Veterans Affairs officials from the USA, the UK, Australia and New Zealand and through an ongoing formal knowledge exchange with the U.S. Department of Veterans Administration’s National Centre for PTSD.

VAC’s Mental Health Strategy will also benefit other organizations or sectors of society. Given that OSI trauma-related symptoms are, in part, similar to civilian trauma-related conditions (such as PTSD following a rape or a catastrophic event), VAC has the unique opportunity to contribute to improving mental healthcare and service delivery to other populations.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
One of the key success factors of VAC’s innovative approach to improving mental health care service delivery for Canadian Veterans suffering from OSIs is that it has been a bottom-up strategy rooted in the needs of clients. Listening to the field – clients, health professionals and partners – and using a shared governance approach was of paramount importance for VAC in building effective, sustainable and transferable programs.

Reaching clients who are not numerous but who are spread across a country as large as Canada, in great urban centres as well as in rural and remote areas, was a challenge that VAC or DND could not meet alone. Joining forces and building on synergies and complementarities is another significant lesson, even though significant differences in organizational cultures as well as administrative resistance had to be overcome along the way. What shattered the barriers was the client perspective that was maintained at every step.

Another important lesson learned was that Veterans, CF or RCMP members suffering from OSIs felt that service providers needed to have some understanding of the military in order to be effective in delivering services and care to meet their needs. For these clients, it was extremely important to feel that whoever was treating them understood the military reality that generated their condition. Such ultra specialized expertise did not exist in Canadian mental health care institutions or programs in 1998 and still seldom exists in most countries faced with increasing prevalence of OSIs rooted in military or peacekeeping operations.

Building a multi-level network integrating two significant government partners and involving provinces, public and private local service providers and universities was another challenge since continuum of care was to be guaranteed throughout these different jurisdictions and since common practices, shared programs and national quality indicators had to be implemented across the different levels of this network. This achievement was unprecedented in Canada and is unique worldwide.

Contact Information

Institution Name:   Veteran’s Affairs Canada
Institution Type:   Government Agency  
Contact Person:   Rachel Corneille Gravel
Title:   Executive Director  
Telephone/ Fax:   514-457-8440
Institution's / Project's Website:   514-457-5747
E-mail:   rachel.gravel@vac-acc.gc.ca  
Address:   305 Bd des Anciens-Combattants
Postal Code:   H9X 1Y9
City:   Sainte-Anne-de-Bellevue
State/Province:   Quebec
Country:   Canada

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