2014 Fall Report of the Auditor General of Canada Chapter 3—Mental Health Services for Veterans

2014 Fall Report of the Auditor General of Canada
Chapter 3—Mental Health Services for Veterans

Introduction

3.1 The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”

3.2 According to the Canadian Mental Health Association, mental illness affects people of all ages, education and income levels, and cultures. Additionally, it states that mental illness indirectly affects many Canadians at some time through a family member, friend, or colleague.

3.3 The economic impact of mental illness on the workplace comes from both lost productivity and disability claims. According to the Mental Health Commission of Canada, mental health conditions cost the national economy an estimated $50 billion a year.

3.4 Mental health conditions affecting Canadians, including veterans, include a broad range of diagnosed medical conditions, such as anxiety disorders, depression, post-traumatic stress disorder (PTSD), alcohol and/or substance abuse, and other conditions that can interfere with daily functioning.

3.5 As of 31 March 2014, about 15,000 War Service Veterans, Canadian Armed Forces Veterans, and still-serving personnel were eligible to receive mental health support from Veterans Affairs Canada through the Disability Benefits Program. An additional 1,000 veterans in the Department’s Rehabilitation Program self-identified as having a mental health condition.

3.6 According to Veterans Affairs Canada, veterans with mental health conditions represent an increasing proportion of its clients, up from less than 2 percent in 2002 to almost 12 percent in 2014. The number of veterans with identified mental health conditions is expected to continue to increase as those with service in Afghanistan return to civilian life, and as awareness and recognition of mental health conditions increase. In the 2012–13 fiscal year, the Department estimated its total mental health expenditures at $508 million for military veterans.

3.7 There are unique challenges in recognizing and treating mental illness, some of which are particularly applicable to veterans. The Canadian Forces Expert Panel on Suicide Prevention produced a report in 2010 that noted that Canadian Armed Forces personnel identified several barriers to mental health care, including

• the military member’s lack of recognition that he or she has a problem,
• the desire to manage one’s problems alone,
• negative attitudes toward mental health care (for example, that it is ineffective or harmful), and
• concern about the career impact of seeking care.

In some cases, the nature of the mental illness may render the individual unable to acknowledge that he or she has a problem. Veterans Affairs Canada’s 2009 Mental Health Strategy states that intervening early is important to delivering effective mental health services to veterans and their families.

Veterans Affairs Canada’s approach to mental health services

3.8 Under the Canada Health Act, all residents of a province, including veterans, are entitled to receive health services, including mental health care, under the terms of their provincial or territorial health care plan. For eligible veterans, the Department pays for various services not covered by provincial health plans. These services can include specialized psychological care, residential treatment, and some prescribed medications. These mental health services are intended to enhance the well-being of veterans, promote independence, and ensure continued care.

3.9 Once their eligibility is confirmed, veterans can access mental health support through the Department’s two programs: the Disability Benefits Program (Disability Benefits) and the Rehabilitation Services and Vocational Assistance Program (Rehabilitation Program). Both released and still-serving members of the Canadian Armed Forces may apply for disability benefits. Only released Canadian Armed Forces members are eligible for benefits under the Rehabilitation Program. National Defence and the Canadian Armed Forces are responsible for providing medical and health care services to military personnel. Exhibit 3.1 describes these programs.

3.10 Exhibit 3.2 shows the time frames within which veterans received a favourable disability benefits decision for a mental health condition under the Disability Benefits Program between 2006 and 2014.

Exhibit 3.2—Time frames for a favourable disability benefits decision for veterans with a mental health condition

[Exhibit 3.2—text version]

Source: Based on data obtained from Veterans Affairs Canada’s Client Service Delivery Network system for disability applications, and for review and appeal applications, from 1 April 2006 through 6 June 2014.

Focus of the audit

3.11 Our audit objective was to determine whether Veterans Affairs Canada has facilitated timely access to services and benefits for veterans with mental illness.

3.12 We examined the management of access to mental health services for veterans. While our audit primarily examined Veterans Affairs Canada, we also looked at two other areas:

• joint initiatives and the transfer of military records with National Defence and the Canadian Armed Forces, and
• information on reviews and appeals by the Veterans Review and Appeal Board.

3.13 Our audit did not include members or veterans of the RCMP, nor did we audit stakeholders such as Health Canada, the provinces, or private sector third parties who provide medical services. We did not assess the appropriateness of eligibility decisions made by Veterans Affairs Canada, the extent to which veterans received eligible mental health services, or the quality of medical treatment and care.

3.14 The audit covered the period from 1 April 2006 to 31 August 2014. We focused mostly on the period from 1 April 2013 to 31 August 2014.

3.15 More details about the audit objective, scope, approach, and criteria are in About the Audit at the end of this chapter.

Observations and Recommendations

Facilitating access to mental health services

3.16 We examined whether Veterans Affairs Canada facilitates timely access to services and benefits for veterans who have been identified by or to the Department as having mental health care needs. Given that an eligibility decision is a prerequisite to obtaining most benefits, we focused on the Department’s processes used to determine eligibility for its rehabilitation and disability benefits programs.

3.17 To assess whether Veterans Affairs Canada was facilitating timely access to services, we analyzed departmental information from the Client Service Delivery Network, through which veterans’ queries and applications are recorded and tracked. We conducted file reviews and analyzed application information from April 2006 through August 2014 for veterans applying for the first time for benefits and/or services related to a mental health condition under the Disability Benefits Program or the Rehabilitation Program. We also analyzed information on the time frames for decisions and appeals.

3.18 Overall, we found that Veterans Affairs Canada is not adequately facilitating timely access to mental health services. Veterans Affairs Canada has put in place important health supports for veterans, and the Department is providing timely access to the Rehabilitation Program. However, access to the Disability Benefits Program—the program through which most veterans access mental health services—is slow, and the application process is complex. We found that Veterans Affairs Canada has not analyzed the time it takes, from a veteran’s perspective, to receive a Disability Benefits eligibility decision. This finding is important because Veterans Affairs Canada has a legislative responsibility to facilitate access to the specialized care required by veterans with mental health conditions.

Veterans Affairs Canada has put in place important mental health supports

3.19 We found that Veterans Affairs Canada has its own programs for veterans and contributes to programs and services of other government departments. In each case, the goal is to facilitate access to services that support veterans with mental health conditions. These programs and services include the following:

• Operational stress injury (OSI) clinics. Veterans Affairs Canada funds nine outpatient clinics and one inpatient clinic that provide assessment, counselling, and treatment services to eligible veterans and Canadian Armed Forces members. These clinics are staffed with psychiatrists, psychologists, social workers, mental health nurses, and other specialized clinicians. Veterans can be referred for assessments without being eligible for other Veterans Affairs Canada programs. Treatment services become available to veterans and to serving military members once Veterans Affairs Canada confirms their eligibility. In addition, seven Operational and Trauma Stress Support Centres, which are operated by National Defence and the Canadian Armed Forces (National Defence), support both eligible veterans and serving military members.
• Case management services. Using case plans, Veterans Affairs Canada case managers help veterans receive a variety of supports, including mental health services. Case managers are members of interdisciplinary teams and have access to doctors, nurses, mental health specialists, and provincial and local programs and service providers. Case managers’ responsibilities for mental health include assessing veterans’ needs, developing case plans, coordinating referrals to mental health care providers, and monitoring progress. These services are primarily available to veterans after eligibility is confirmed.
• Veterans Affairs Canada Assistance Service. Health Canada delivers this 24/7 telephone service for all veterans and their families to enable them to reach a mental health professional at any time. The service is also available to primary caregivers who have personal concerns that affect their well-being.
• Operational Stress Injury Social Support Program. This program is funded jointly by Veterans Affairs Canada and National Defence. Peer support is available to veterans and their families through trained peer support coordinators and volunteers who have also dealt with operational stress injuries.

Access to mental health support under the Rehabilitation Program is timely

3.20 The Rehabilitation Program is one of two gateways through which veterans can access Veterans Affairs Canada mental health care support. As of March 2014, 4,600 veterans with mental health conditions were in the Rehabilitation Program. Of these, 3,600 veterans were also receiving disability benefits for a mental health condition under the Disability Benefits Program.

3.21 The Rehabilitation Program is not intended to be long-term, and treatment and benefits end once a veteran completes the program. Eligibility requirements for the Rehabilitation Program are less stringent than those of the Disability Benefits Program. Veterans who are medically released are automatically eligible for the Department’s Rehabilitation Program and mental health support if they apply within 120 days of their release from the Canadian Armed Forces. Any veteran may apply beyond the 120-day period provided they can demonstrate that they have a health problem arising primarily from military service and preventing their integration into civilian life.

3.22 A veteran in the Rehabilitation Program is assigned a case manager who determines the veteran’s mental health care requirements, develops a case plan, and monitors the veteran’s progress. Rehabilitation Program participants who are not yet in treatment can access treatment once the case manager has prepared a case plan and approved treatment (Exhibit 3.3).

Exhibit 3.3—The Rehabilitation Program application process

[Exhibit 3.3—text version]

Note: In its documentation, Veterans Affairs Canada expresses its service standards in “weeks” for making an eligibility decision and in “days” for assessing a veteran and preparing a case plan.

Source: Information obtained from Veterans Affairs Canada's published service standards and internal documentation.

3.23 The Department has not established a standard for the time it should take a veteran to access treatment and services under the Rehabilitation Program. However, the Department does have a standard of making 80 percent of eligibility decisions within two weeks of determining that the veteran’s application is complete. The Department has also established a standard for preparing case plans within 45 days of a favourable eligibility decision. The combination of the time required to decide on eligibility and the time required to assess a veteran and prepare a case plan may affect how long a veteran will have to wait for mental health services.

3.24 We found that in the 2013–14 fiscal year, the Department made 84 percent (1,136 of 1,349) of eligibility decisions under the Rehabilitation Program within the two-week service standard. We measured the response from the time the application was considered complete, for veterans with an identified mental health condition. We also found that the majority of case plans were prepared within 45 days. Veterans Affairs Canada is meeting its service standards for providing timely access to mental health services through the Rehabilitation Program.

Eligibility decisions under the Disability Benefits Program are not timely

3.25 As of 31 March 2014, more than 94 percent (about 15,000 of 16,000) of veterans eligible for mental health support from Veterans Affairs Canada had access to support through the Disability Benefits Program. To be approved for mental health support under the Disability Benefits Program, veterans must provide evidence that military service caused or aggravated a chronic mental health condition. This eligibility requirement is more stringent than that of the Rehabilitation Program. The application process is outlined in Exhibit 3.4.

Exhibit 3.4—The Disability Benefits Program application process

[Exhibit 3.4—text version]

Sources: Based on information obtained from Veterans Affairs Canada’s published service standards and internal documentation, and from Veterans Affairs Canada’s Client Service Delivery Network system for disability applications for the 2013–14 fiscal year.

3.26 We looked at the first applications submitted by veterans for a disability benefit for a mental health condition in the 2013–14 fiscal year to determine how long it took for veterans to receive an eligibility decision under the Disability Benefits Program. Veterans Affairs Canada has a target of providing 80 percent of applicants with a decision on their eligibility within 16 weeks from the date the Department considers the application to be complete. If the Department determines that the submitted application is complete, the receipt date is Veterans Affairs Canada’s starting point for measuring time. We found that the Department did not meet its target in the 2013–14 fiscal year, as 75 percent (2,160 of 2,893) of decisions on first applications for mental health conditions were processed within 16 weeks. This means that 733 veterans did not receive a decision within the 16-week standard. Veterans Affairs Canada’s standard is to provide a veteran with a health benefits card within 6 weeks of approving the veteran’s application. This card allows direct billing from the service provider to the Department.

3.27 We found that from the veterans’ perspective, it takes about twice as long as the Veterans Affairs Canada standard (32 weeks compared with 16 weeks) for 80 percent of veterans to receive an eligibility decision (Exhibit 3.5). This timing is due in part to the barriers veterans must overcome to complete the application process. We discuss the various barriers in paragraphs 3.30 to 3.43.

Exhibit 3.5—Veterans Affairs Canada and veterans have different perspectives on the time it takes to make a decision on eligibility for disability benefits

[Exhibit 3.5—text version]

Source: Based on data obtained from Veterans Affairs Canada’s Client Service Delivery Network system for disability applications for the 2013–14 fiscal year.

3.28 In our opinion, it is important to assess what occurs before the Department deems an application complete. We recognize that Veterans Affairs Canada cannot control all factors contributing to elapsed time from the first contact by a veteran until an application is determined complete. However, analyzing total elapsed time can both help identify barriers that veterans face when applying for benefits and point to potential remedies. Without this information, the Department cannot effectively act to remove barriers it controls or work with other stakeholders to remove barriers they control.

3.29 Veterans Affairs Canada advised us that delays in determining eligibility do not prevent veterans from getting mental health care. We selected a random sample of 47 veterans determined eligible for mental health support in the 2013–14 fiscal year. We found evidence that 17 of these veterans received mental health care while waiting for an eligibility decision. We did not find evidence to indicate whether 11 others had. Our sample included 19 still-serving veterans who received a disability award. Veterans Affairs Canada advised us that National Defence is responsible for providing mental health care to these 19 veterans, and that therefore Veterans Affairs Canada does not track whether they received care. Our recommendation is found at paragraph 3.33.

There are long-standing barriers to timely access to disability benefits

3.30 We wanted to identify barriers to timely eligibility decisions under the Disability Benefits Program. Some of the barriers are outside Veterans Affairs Canada’s control. For example, long wait-lists for family doctors can delay referrals to mental health specialists. However, we found that there are some barriers to veterans’ receiving more timely eligibility decisions that are within Veterans Affairs Canada’s and National Defence’s control. These barriers are

• a complex application process,
• delays in obtaining medical and service records from National Defence, and
• long wait times at operational stress injury clinics for getting a qualified health care professional to assess a mental health condition.

3.31 Complexity of the application process. As part of our audit, we surveyed the Royal Canadian Legion service officers who represent veterans and complete their applications. We wanted to find out how these officers viewed the application and appeal processes. Service officers stated that the application process could be streamlined. For example, veterans should not be required to complete the application and quality of life questionnaire if they already received a diagnosis while serving in the military, as documented in service and health records.

3.32 Our survey results also noted that veterans find the application process complex and time-consuming. We agree. In addition to completing a Disability Benefits application and a four-page quality of life questionnaire, veterans are asked to provide detailed information about claimed operational stress injuries, such as dates, circumstances, and medical treatment, and if available, military occupation codes, duties, and time spent in locations. This information should be included in the service records that Veterans Affairs Canada requests from National Defence as part of the application process. In the 2014–15 fiscal year, Veterans Affairs Canada began an initiative to contact veterans whose applications are missing information with a view to having the application complete. We noted that in August 2014, after we completed our above-mentioned survey, Veterans Affairs Canada provided the Legion with its proposed streamlined Disability Benefits application form. The Legion has responded positively to these proposed amendments.

3.33 Recommendation. Veterans Affairs Canada should analyze the Disability Benefits application process, quantify and document barriers to timeliness, and take corrective action. In particular, Veterans Affairs Canada should help those veterans who may require additional assistance with the application process.

3.34 Delays in obtaining military records. In the 2012 Fall Report of the Auditor General of Canada, Chapter 4, Transition of Ill and Injured Military Personnel to Civilian Life, we noted that National Defence and Veterans Affairs Canada recognized the importance of reliable and timely information. They acknowledged the need to improve their information-sharing systems and identified the Transfer of Electronic Health and Administrative Records initiative as a joint priority. Under this priority, their goal was to streamline interdepartmental functions. The 2012 audit noted that more needed to be done both to ensure the accuracy of information on Canadian Armed Forces members and to pass authorized information to Veterans Affairs Canada in a timely manner.

3.35 In 2012, Veterans Affairs Canada and National Defence initiated a pilot project to improve the process for providing health information. A team of 10 Canadian Armed Forces reservists was established to receive requests for medical and service records and send the documents electronically to Veterans Affairs Canada. National Defence informed us that the pilot is now over. This new process has been in full implementation since May 2014. Officials advised us that the time frame for transferring records has improved from 18 months to approximately 16 weeks.

3.36 In our view, a 16-week wait for service and medical records is still not timely. Waiting for these records can account for up to one half of the time required to decide on eligibility.

3.37 Recommendation. National Defence and the Canadian Armed Forces should take further steps to accelerate the transfer of service and medical records to Veterans Affairs Canada.

National Defence and the Canadian Armed Forces’ response. Agreed. The Canadian Forces Health Services Group and Veterans Affairs Canada are dedicated to jointly seeking continuous improvement in the transfer of files between the two departments. Together, the Canadian Forces Health Services Group and Veterans Affairs Canada have doubled the number of people dedicated directly to the file transfer endeavour (the team will grow from the original 10 reservists to a joint reservist/temporary help team of 20 by the end of October 2014), while at the same time exploring options with Public Works and Government Services Canada to further accelerate the process through contracted solutions.

3.38 Wait times for assessment at operational stress injury (OSI) clinics. As part of the Disability Benefits Program application, a veteran must submit a medical diagnosis or an assessment from a licensed health professional that includes an opinion on contributing factors, such as any relationship between the psychiatric condition and military service. These assessments may be provided by mental health professionals who work in Veterans Affairs Canada’s OSI clinics or National Defence’s Operational and Trauma Stress Support Centres. Many of these professionals specialize in care for OSIs. The assessment will provide an opinion on whether the mental health condition relates to military service. OSI clinics provide both assessments and treatment. Veterans Affairs Canada has not tracked wait times specifically for assessments at the OSI clinics but has told us that it intends to begin reporting wait times for assessments at OSI clinics on its website in October 2014.

3.39 Veterans Affairs Canada’s standard is to assess 80 percent of new clients at OSI clinics within three weeks of referral. However, staff at one regional office told us that wait times for assessments at the nearest OSI clinic can be up to four months. Veterans Affairs Canada has indicated that the average wait times from referral are about three months.

3.40 Veterans may also receive mental health services at National Defence’s Operational and Trauma Stress Support Centres. National Defence tracks assessment wait times at these centres. According to National Defence, from January to June 2014, wait times at four of seven centres met its 36-day standard for an initial assessment. In the three other centres, wait times were longer than 50 days.

3.41 Delays in obtaining assessments, whether through Veterans Affairs Canada or National Defence clinics, contribute to delays in the veteran’s application for disability benefits. These delays may jeopardize a veteran’s stabilization and/or recovery. National Defence needs to work with the Operational and Trauma Stress Support Centres to implement solutions with the objective of providing timely psychological and psychiatric assessments. These changes could help improve wait times for veterans and speed eligibility decisions.

3.42 Recommendation. Veterans Affairs Canada should work with the operational stress injury clinics to implement solutions to provide timely access for psychological and psychiatric assessments.

3.43 Recommendation. National Defence and the Canadian Armed Forces should work with the Operational and Trauma Stress Support Centres to implement solutions to provide timely access for psychological and psychiatric assessments.

National Defence and the Canadian Armed Forces’ response. Agreed. National Defence and the Canadian Armed Forces will continue to track the wait times on a monthly basis and determine the factors contributing to wait times beyond the established benchmark. Staffing levels and business processes will be examined and adjustments made as required. The use of telehealth will also be explored as a way for clinics that are not as busy to help those experiencing higher demands.

Veterans Affairs Canada does not analyze appeal and review decisions to identify systemic problems in its application process

3.44 Veterans can challenge a negative eligibility decision (Exhibit 3.6). Of the 15,385 veterans who applied for disability benefits for a mental health condition between April 2006 and June 2014, 3,684 (24 percent) were denied benefits. Of those denied applicants, 1,297 challenged Veterans Affairs Canada’s decision. We analyzed data on the results for veterans whose first application was denied and found that 65 percent (843 of 1,297) who challenged a denied eligibility decision did so successfully.

3.45 We also analyzed the total elapsed time for a veteran to get a favourable decision, from time of initial contact with Veterans Affairs Canada until the final review or appeal decision. There is no time limit for a veteran to apply for a review or appeal with the Veterans Review and Appeal Board. Of the 843 veterans with a mental health condition who successfully challenged their denied eligibility, 695 waited between six months and three years for a favourable decision. Furthermore, 128 veterans waited from three to more than seven years to receive a favourable decision.

3.46 We found that Veterans Affairs Canada knows that most successful reviews and appeals rely on new information or testimony presented by the veteran or the veteran’s representative. Such decisions have resulted in amendments to departmental policies. However, the Department has not analyzed what types of information result in successful reviews and appeals to determine if application and eligibility determination processes require modifications. Such analysis may identify whether the Department can improve its application process to ensure that the required information is on file when making eligibility decisions. In November 2013, the Veterans Review and Appeal Board put in place a process to inform Veterans Affairs Canada of reasons for overturning its decisions. In our view, it is important that the Department determine what type of information it needs to reduce reviews and appeals.

3.47 Recommendation. Veterans Affairs Canada should work with the Veterans Review and Appeal Board to identify whether reasons for successful reviews and appeals indicate a need to modify the application process.

Providing mental health outreach

3.48 Veterans Affairs Canada’s annual departmental performance reports and its Mental Health Strategy recognize the importance of outreach in contributing to the well-being of veterans and other stakeholders. Outreach is an important tool for raising awareness of the Department’s programs with veterans and a broad range of stakeholders, such as doctors, families, and veteran advocacy organizations. We considered medical practitioners, families, and veteran advocacy organizations to be primary stakeholders.

3.49 We examined whether Veterans Affairs Canada has developed and implemented an outreach strategy to raise veterans’ and stakeholders’ awareness of the supports available to meet veterans’ mental health needs.

3.50 Overall, we found that Veterans Affairs Canada’s mental health outreach strategy is not comprehensive enough. The strategy focuses on existing veteran clients and military members who are about to be released. We noted that more could be done to reach family doctors and families of veterans.

Veterans Affairs Canada outreach activities are not comprehensive enough

3.51 The Department’s most recent outreach strategy is the 2011–12 outreach and communications strategy. This document defines outreach as “the process to educate and engage target audiences about the services and programs provided by Veterans Affairs.” The strategy’s objective is to help veterans and Canadian Armed Forces members and their families better understand and accept the services and benefits Veterans Affairs Canada provides. The Department also prepared annual outreach, consultation, and engagement plans for the 2012–13 and 2013–14 fiscal years. A list of outreach activities is provided in Exhibit 3.7.

3.52 Stakeholders. Veterans Affairs Canada views primary stakeholders to be members of the Canadian Armed Forces or Reserve Force, members, veterans, veterans’ families, and internal stakeholders, such as management and front-line staff of Veterans Affairs Canada and of National Defence and the Canadian Armed Forces (National Defence), and the National Call Centre Network. According to the Mental Health Commission of Canada, “People are more likely to consult their family physician about a mental health problem or illness than any other health care provider.” Although Veterans Affairs Canada has carried out some targeted outreach to family doctors in the past, we found that family doctors were not identified as stakeholders in the Department’s 2011–12 Outreach and Communications Strategy.

3.53 As a key priority in its Outreach, Consultation and Engagement Annual Plan 2013–14, Veterans Affairs Canada committed to carrying out consultations to decide how best to reach family physicians. The Department wants to let these physicians know about Veterans Affairs Canada benefits and services, and about veteran health and disability conditions. The Department told us that consultations will take place with family physicians in 2014. The Department has updated its website to include information for mental health providers, but it did not include family doctors on its list of medical service providers. In our opinion, the Veterans Affairs Canada website should include information targeted to family doctors. Our recommendation regarding stakeholders is found at paragraph 3.58.

3.54 Outreach activities. Veterans Affairs Canada does not educate family members on possible signs of mental illness. Both families and family doctors have the potential to encourage veterans with mental health conditions to seek help. This is important because veterans may be reluctant to seek help or may not realize they are having difficulties. We found that the Department needs to do more, such as increase consultations with families and family doctors to support their encouragement of these veterans to seek help.

3.55 Veterans Affairs Canada’s outreach strategy recognizes the need to reach reservists. Statistics Canada conducted a study on behalf of Veterans Affairs Canada and National Defence. The 2013 Life after Service Study reported on the health and well-being of Canadian Armed Forces veterans. It found that the prevalence of mood disorders in Class C reservists was 12 percent, compared with 7 percent in the Canadian population. Higher rates of mental health conditions in reservists reinforces the importance of targeted outreach to this group. Veterans Affairs Canada is developing a targeted plan for outreach to Reserve Force veterans.

3.56 Veterans Affairs Canada’s outreach strategy also notes the importance of identifying certain groups of veterans as priorities. Veterans released from the Canadian Armed Forces more than 15 years ago are one such group. These veterans are the least likely to know about Veterans Affairs Canada programs.

3.57 As part of our audit, we surveyed 24 stakeholder interest groups. According to the results of our survey, the most commonly raised concerns were that veterans do not know the extent of services available and that the website is challenging to navigate. In our opinion, these concerns indicate a need for more outreach to veterans.

3.58 Recommendation. Veterans Affairs Canada should update its outreach strategy to include family physicians. The Department should also carry out an outreach strategy that meets the needs of all target audiences.

Managing the Mental Health Strategy

3.59 Organizations use strategic planning as a management tool to define long-term objectives and measure progress toward goals. We examined whether Veterans Affairs Canada has developed and carried out a strategic approach to define and address the mental health needs of veterans. We also examined whether Veterans Affairs Canada has performance information to assess the effectiveness of mental health support provided to veterans.

3.60 Overall, we found that while Veterans Affairs Canada has developed a mental health strategy, it does not collect information or report on the effectiveness of it. This finding is important because the information would help Veterans Affairs Canada focus its resources to achieve its strategic objectives, determine whether it is achieving these objectives, and adjust its strategy as required to ensure that veterans receive the mental health services they need.

The Department has developed a Mental Health Strategy, but has not assessed and reported on how well this strategy is working

3.61 Mental health strategy. Veterans Affairs Canada developed its most current strategy in 2009. We looked at the content of the 2009 Mental Health Strategy, the strategic plan, and departmental performance reports for the 2008–09 to 2012–13 fiscal years. A good strategy and plan would have identified the mental health needs of veterans, the steps to address these needs, and the ways to assess whether these needs had been met.

3.62 Veterans Affairs Canada’s 2009 Mental Health Strategy includes a priority of “providing access to a comprehensive suite of mental health programs and services.” The strategy references more than 30 programs and services available to help eligible veterans cope with mental health issues. It also includes a framework “through which Veterans Affairs will evaluate the outcomes and quality of service provided to clients with mental health conditions.” The strategy includes the priority of “building capacity across the country that provides specialized care to clients with mental health conditions associated with operational stress injuries.”

3.63 Measuring the effectiveness of outreach activities. Despite its many outreach activities, Veterans Affairs Canada collects data only on how satisfied releasing Canadian Armed Forces members are with the information sessions they receive before they are released from service. We found that Veterans Affairs Canada does not have data to assess the effectiveness of its mental health outreach activities as a whole. Such information is important to show whether outreach activities are achieving their purpose of improving the dissemination of information on mental health and whether veterans are receiving the mental health services they need. We noted that the results of the evaluation of the Department’s most recent media advertising campaign will be reported in the late fall of 2014. Our recommendation regarding measurement is found in paragraph 3.67.

3.64 Reporting on the strategy. Veterans Affairs Canada needs to know if the support provided meets the mental health needs of veterans. The Department made a commitment in its 2009 Mental Health Strategy to develop performance measures to assess the success of its mental health strategy. We found that Veterans Affairs Canada has not yet developed these measures. Further, the performance measures in place provide information on many aspects of veterans’ well-being but omit specific information on veterans’ mental health. Finally, the Department’s performance measures focus on the number of veterans served and the timeliness of service rather than on the quality of service and the impact on veterans’ lives. As a result, the Department cannot report whether its strategy is successful and if veterans’ mental health needs are being met. The absence of specific mental health measures means that Veterans Affairs Canada does not have the information on results that would serve as a catalyst for corrective action.

3.65 Veterans Affairs Canada is in the initial stages of implementing the Client-Reported Outcome Monitoring Information System (CROMIS) in the OSI clinics. Veterans will be able to access the system and input information about their state of mental health and their treatment. The information collected from veterans will be used by the OSI clinics to monitor veterans’ mental health. This monitoring may help to identify those at risk and provide actionable, timely, and evidence-informed recommendations to the veteran and the mental health service provider.

3.66 In our view, CROMIS is a positive approach to capturing important information on the well-being of veterans treated at the OSI clinics. The Department informed us that it might broaden access to this system beyond the OSI clinics. Veterans Affairs Canada officials told us that information in the system, once rolled out, may be useful in assessing the success of the Department’s mental health strategy.

3.67 Recommendation. Veterans Affairs Canada should assess and report on the effectiveness of its Mental Health Strategy and develop performance measures for its strategy and outreach activities for veterans with mental health conditions.

Veterans Affairs Canada’s response. Agreed. Given that Veterans Affairs Canada’s Mental Health Strategy is delivered through the Department’s different programs, performance indicators from the different program areas are used to measure its effectiveness. The Department agrees that moving forward, additional performance measures can be put in place to measure the specific mental health initiatives/outreach activities and strategic directions that will be reflected in the Department’s upcoming new Mental Health Strategy.

Conclusion

3.68 We concluded that Veterans Affairs Canada is facilitating timely access for veterans to the Rehabilitation Program. Access to the Disability Benefits Program, through which the majority of veterans receive long-term mental health support, is not timely.

3.69 Access to the Disability Benefits Program is slow and the application process is complex. Veterans Affairs Canada does not meet its published standard of making 80 percent of eligibility decisions within 16 weeks, and it does not analyze the time that lapses between a veteran’s contacting the Department and the Department’s deciding on the veteran’s eligibility. Veterans Affairs Canada, and National Defence and the Canadian Armed Forces, control a number of long-standing factors that, if addressed, could help reduce the time for veterans to complete applications, receive eligibility decisions, and access mental health support.

3.70 While Veterans Affairs Canada provides a variety of outreach activities to its existing clients, the Department could do more for other key stakeholders, such as family physicians.

3.71 While Veterans Affairs Canada has developed a mental health strategy, it has not developed performance measures that adequately focus on mental health. The performance measures in place provide information on many aspects of well-being but not specifically on mental health. Veterans Affairs Canada’s performance measures focus on how many veterans are being served and how timely veterans are being served, rather than on how well veterans are being served and whether programs are making a difference in their lives. As a result, Veterans Affairs Canada is not able to demonstrate that services provided to meet the mental health needs of veterans are effective.

About the Audit

The Office of the Auditor General’s responsibility was to conduct an independent examination of mental health services to veterans to provide objective information, advice, and assurance to assist Parliament in its scrutiny of the government’s management of resources and programs.

All of the audit work in this chapter was conducted in accordance with the standards for assurance engagements set out by the Chartered Professional Accountants of Canada (CPA) in the CPA Canada Handbook—Assurance. While the Office adopts these standards as the minimum requirement for our audits, we also draw upon the standards and practices of other disciplines.

As part of our regular audit process, we obtained management’s confirmation that the findings reported in this chapter are factually based.

Objective

The audit objective was to determine whether Veterans Affairs Canada has facilitated timely access to services and benefits for veterans with mental illness.

Scope and approach

We examined the management of access to mental health services for veterans. While our audit primarily examined Veterans Affairs Canada, we also looked at the transfer of military records and joint initiatives with National Defence and the Canadian Armed Forces, and information on reviews and appeals by the Veterans Review and Appeal Board. The audit covered the period from 1 April 2006 to 31 August 2014, focusing on the period from 1 April 2013 through to the completion of the audit on 31 August 2014.

Our audit did not include members and veterans of the RCMP, nor did we audit stakeholders such as Health Canada, the provinces, or private sector third parties who provide medical services. We did not assess the appropriateness of eligibility decisions made by Veterans Affairs Canada, the extent to which veterans received all eligible mental health services, or the quality of medical treatment and care provided. The audit focused on the activities of Veterans Affairs Canada with respect to its support of veterans with mental illness. National Defence and the Canadian Armed Forces are included because they are key partners of Veterans Affairs Canada in supporting veterans with mental illness.

The selected Veterans Affairs Canada programs, services, and benefits for supporting mentally ill veterans included

• case management services,
• the Disability Awards Program,
• the Disability Pension Program,
• health care benefits,
• the Operational Stress Injury Clinic Network,
• the Operational Stress Injury Social Support Program, and
• the Rehabilitation Services and Vocational Assistance Program.

The audit approach included reviewing selected departmental policies, systems, and practices, as well as other relevant documents. It also included interviewing responsible departmental officials at headquarters and in three regions (Atlantic, Quebec, and Western), in addition to representatives of selected veterans’ organizations.

We also obtained audit evidence by conducting file reviews and analyzing the databases that contain veterans’ records from across Canada for the period of 1 April 2006 to 6 June 2014. As well, audit evidence was collected through two surveys directed to the Royal Canadian Legion and a sample of stakeholders. We provided Veterans Affairs Canada with a draft of the surveys in advance for comments.

Acknowledgement

In paragraph 3.1, we used the definition, with the permission of the publisher, from Mental health: a state of well-being, Geneva, World Health Organization, 2014 (accessed on 14 August 2014).

Criteria

To determine whether Veterans Affairs Canada has facilitated timely access to services and benefits for veterans with mental illness, we used the following criteria:

The management of Veterans Affairs Canada, the Veterans Review and Appeal Board, and National Defence and the Canadian Armed Forces reviewed and accepted the suitability of the criteria used in the audit.

Period covered by the audit

The audit covered the period from 1 April 2006 to 31 August 2014, focusing on the period from 1 April 2013 through to the completion of the audit on 31 August 2014.

Audit team

Assistant Auditor General: Jerome Berthelette
Senior Principal: Bruce C. Sloan
Director: Dawn Campbell

Françoise Bessette
Arethea Curtis
Marie-Claude Dionne
Lisa Seguin

For information, please contact Communications at 613-995-3708 or 1-888-761-5953 (toll-free).
Hearing impaired only TTY: 613-954-8042

Appendix—List of recommendations

The following is a list of recommendations found in Chapter 3. The number in front of the recommendation indicates the paragraph where it appears in the chapter. The numbers in parentheses indicate the paragraphs where the topic is discussed.

Facilitating access to mental health services

Providing mental health outreach

Managing the Mental Health Strategy