Veterans' Long-Term Care Needs

Introduction

Our nation has a long and distinguished military history by virtue of its participation in several wars, internal conflicts, the battle against terrorism, peacekeeping efforts and the defense of our sovereign territory. Because of its commitment to our servicemen and women, the Canadian Government, through Veterans Affairs Canada, has supported a wide variety of health initiatives and benefits that are designed to ensure the continued physical and emotional well-being of our Veterans. While the various programs sponsored by Veterans Affairs Canada have evolved over the years to address the changing needs of its clientele, they continue to provide funding as a contribution towards critical medical assistance and other financial support to our aging, injured and disabled Veterans.

The three pillars of Veterans Affairs Canada's health and medical support programs are the Long-Term Care Program, the Health Benefits Program (Programs of Choice), and the Veterans Independence Program. The Long-Term Care Program specifically addresses the needs of those eligible Veterans who may be aging, injured or disabled and require intensive institutional-based medical supervision because of their failing physiological and/or emotional health. The Health Care Benefits Program provides financial support to qualified Veterans for the health care services that are available through the Department's 14 Programs of Choice. Benefits such as aids for daily living, hearing services, dental care, medical supplies, nursing services, oxygen therapy, vision care and prescription drugs are examples of the benefits made available through Veterans Affairs Canada's Programs of Choice.

The Veterans Independence Program is Veterans Affairs Canada's flagship home and residential care program. It provides assistance to qualified Veterans, their survivors/primary caregivers and certain civilians, as defined in the Veterans Health Care Regulations, so they can maintain their health, quality of life, dignity and independence in their homes and residences for as long as possible. At the point where it is no longer medically advisable or safe for a Veteran to remain in the home, the Veterans Independence Program can provide qualified Veterans with funding as a contribution towards intermediate care, subject to availability, in a facility in the community where he or she resides. Overall, the Veterans Independence Program is designed to complement existing federal, provincial and municipal health care programs in the provision of services and benefits that are not otherwise accessible to Veterans as residents of their home province.

The program objectives of the Veterans Independence Program are to:

• Offer supportive service and intervene only to the extent that health needs cannot be met through personal and family support, or through provincial and community programs;
• Recognize the right and responsibility of the individual to remain at home for as long as it is reasonable, safe and practical to receive Veterans Independence Program services;
• Promote personal independence, as well as personal and familial responsibility in planning and providing care appropriate to the Veteran's health needs;
• Encourage an independent lifestyle to whatever degree possible; and
• Meet the health needs of Veterans in a cost-effective manner.^{Footnote 1}

This Review will examine the Veterans Independence Program and focus on three aspects that affect the way services are delivered to and received by clients. Specifically, we will look at the eligibility, accessibility and cost factors of the program and highlight areas of concern arising out of those elements. We will see that the Veterans Independence Program, as it currently exists, employs a complex set of eligibility criteria and applies different eligibility rules to the various categories of eligible Veterans. Additionally, once a Veteran meets the eligibility requirements of a given group, there appear to be significant gaps in the extent to which the different client groups can access benefits. In other words, one group of Veterans may be unable to access medically necessary benefits, while another may have full entitlement by virtue of the client group to which they belong. Veterans, their families, as well as several groups of interested stakeholders shared these concerns with the Veterans Ombudsman.

The Veterans Independence Program Review is the second in a series of three papers produced by the Office of the Veterans Ombudsman that examines the provision of health benefits by Veterans Affairs Canada to our Veterans, family members, survivors and caregivers. To complement this paper, a Review on Veterans Affairs Canada's Long-Term Care Program has been published. The third instalment will be a full review of publicly and privately funded assisted living options for Veterans whose health status would enable them to benefit from such a model of shelter and care. The series will conclude with a Continuum of Care Report containing recommendations in relation to all three review paper subject areas.

Background

As far back as the late 1950's, the Canadian Government was aware that the military Veteran population was aging quickly and would soon present a major challenge in terms of requiring increasing benefit levels and medical supports. Faced with a cohort of approximately one million Second World War Veterans with an older age profile than the general population, the Government authorized eligible Veterans serving overseas in a time of war access to institutional care in a long-term care facility. As a result of this commitment, and in an effort to offer an alternative to the ever-increasing numbers of Veterans accessing long-term care, in 1981 the Aging Veterans Program was born.^{Footnote 2}

Renamed the Veterans Independence Program in 1986, the objective of this innovative home care and health support initiative was to ensure that Veterans who required additional assistance with their activities of daily living could safely remain in their own homes and live out their lives with their spouses or partners in an atmosphere of independence and dignity. Remaining in one's home would also afford Veterans with a number of other benefits that are difficult to measure but are essential elements in the maintenance of physical and emotional well-being, including:

• The ability to be supported directly by spouses or partners;
• The maintenance of independence through the management of one's own affairs;
• The proximity of family supports;
• A network of friends, other seniors and fellow Veterans; and
• Familiarity with their environment and surroundings.

The Veterans Independence Program: Benefits and Services

Today's Veterans Independence Program

The Veterans Independence Program is delivered by Veterans Affairs Canada and operates under the regulatory authority of section 5(1) of the Department of Veterans Affairs Act, and the regulatory authority of Part II of the Veterans Health Care Regulations. Its primary focus is to provide funding as a contribution towards a wide range of services that allow Veterans to remain healthy, safe and independent in their homes for as long as possible. Under the home care benefit program, a Veteran can receive funding for assistance with both activities of daily living, and instrumental activities of daily living, such as:

Activities of Daily Living:

• Nutrition
• Personal care and hygiene
• Health and support services

Instrumental Activities of Daily Living:

• Health and support services
• Housekeeping
• Ground maintenance
• Transportation
• Home adaptations
• Ambulatory Health Care

Examples of Veterans Independence Program home based services available to Veterans and their caregivers include:

• Grounds maintenance such as lawn mowing and snow removal, which the client would normally perform and is responsible for (but for the health impairment), and there is no relative living in the home willing and able to provide the service.
• Housekeeping tasks or domestic chores to assist with daily living for which the client has responsibility and would normally perform (but for the health impairment), and there is no relative living in the home willing and able to provide the service. These tasks include, but are not limited to laundry, grocery shopping, meal preparation, and vacuuming.
• Personal care by a non-health professional. Assistance with daily activities such as bathing, dressing, and eating.
• Access to nutrition.
• Health and support services by a health professional, such as nursing care, therapy and personal care.
• Ambulatory health care such as health assessments, diagnostic services and social and recreational services provided by a health professional as well as transportation to access these services.
• Transportation to foster independence and to avoid social isolation and for activities such as shopping, banking, attending senior citizen centres and churches, and visiting friends when transportation is not otherwise available. Transportation is only available to War Service Veterans assessed as low income.
• Home adaptations to the principal residence to enable the client to perform activities of daily living, as well as adaptations to modify bathrooms, kitchens and doorways so that it is easier for the client to perform basic everyday activities such as meal preparation. Home adaptations do not include general renovations or repairs.^{Footnote 3}

When Health Needs Increase – Continuation of Benefits

When the health status of a Veteran changes to the extent that they have been assessed as having a level II ^{Footnote 4} or greater health need, and an appropriate bed is not available or the Veteran chooses for one reason or another to remain in the home, the program allows for the continuation of home care benefits.

The Veterans Program Policy Manual states that the purpose of continuing home care benefits, “... is to recognize and take into consideration the client's right to self-determination in their choice of care setting, while striving for optimal health outcomes and being mindful of responsible spending”.^{Footnote 5} However, this provision is not intended to provide long-term chronic care in the Veteran's residence.

Intermediate Care

Amongst its benefit programs, the Veterans Independence Program provides funding as a contribution towards “Intermediate Care”, formerly known as Nursing Home Intermediate Care.

Intermediate Care is the provision of short-term assistance in a community facility, other than in a contract bed, including:

• Daily nursing and personal care under the direction or supervision of qualified medical and nursing staff;
• Assistance with the activities of daily living, and any social, recreational and other related services provided to meet the psychosocial needs of the residents of the facility; and
• Accommodation and meals.

Eligibility for Intermediate Care is dependent upon the Veteran's classification and whether they meet one or more of Veterans Affairs Canada's many eligibility criteria. Intermediate care is the provision of services, required to meet a need for personal care on a continuing basis under the supervision of a health professional, where a person has a functional disability, has reached the apparent limit of recovery and has little need for diagnostic or therapeutic services. These requirements would include a moderate amount of daily nursing and personal care as well as assistance with daily living activities. It is also used when a Veteran has been discharged from a higher care level facility (acute care or otherwise) and is transitioning back to his/her home, but still requires a level of care and supervision that might not be otherwise available through home care supports.

In Veterans Affairs Canada's Audit and Evaluation Division's Evaluation of the Veterans Independence Program – Final July 2011, the evaluation team's file review and client interviews showed that certain Veterans were receiving long-term type care through the Veterans Independence Program's version of intermediate care even though their assessed medical needs were beyond Type II and fit the criteria for Type III.^{Footnote 6} In cases when perhaps the individual's eligibility under their client group might not qualify them for long-term care under the Long-Term Care Program, intermediate care under the Veterans Independence Program was being used as a gateway by client service personnel to approve long-term care services and benefits for certain groups of Veterans, such as Regular and Reserve Force Members, in spite of the limitations of the eligibility rules. While it is clear that the pressing need for long-term care in those client groups is being satisfied, this creative client service approach illustrates the requirement to re-assess how long-term care benefits are accessed and to re-evaluate the eligibility criteria for those client groups.

The use of either the Long-Term Care or Veterans Independence Programs to facilitate the same level of care was evident in Veterans Affairs Canada's Audit and Evaluation Division's report:

“Due to the fact that VAC care levels and provincial care levels may differ, as well as the fact that LTC contract beds are more costly, two recipients could be in the same facility, under two different VAC programs, at two different rates receiving the same level of care.”^{Footnote 7}

The audit team took their findings one step further. They concluded that:

Adult Residential Care (pre-1993, grandfathered)

In 1993, the Adult Residential Care Program that had previously been available to Veterans was removed as a Veterans Independence Program service. Those Veterans who were approved for the Adult Residential Care Program prior to the 1^st of July 1993 were grandfathered for this type of care. Adult Residential Care consists of care provided in a health care facility to meet a Level I Health Need.^{Footnote 9} It was designed to address the Veteran's need for:

• Personal and supervisory care;
• Assistance with the activities of daily living, and any social, recreational and other related services to meet the psychosocial needs of the residents of the facility; and
• Accommodation and meals.

Respite Care

Veterans Affairs Canada recognizes the demanding nature of care giving and the toll it can take on family members who look after and support Veterans. The Veterans Independence Program provides funding for respite care for family members to ensure that they have the opportunity to rest and recover from their care giving duties. While all provinces provide some form of respite care through their home care programs, each program differs in the type and level of services offered. The Department will supplement provincial programs through a combination of health care benefits, Veterans Independence Program services and long-term care designed to meet the specific health care needs of the eligible client.

Funding for respite care can be provided in two types of situations:

• Where the eligible client is in need of care; or
• To a more limited extent, where the eligible client is the caregiver.

When the eligible client is the care recipient, the purpose is to provide care for that person; this results in respite for the client's caregiver. The tasks that are performed or the services that are provided fall within the services for which the client is eligible, such as:

• Health care benefits such as the provision of special equipment (e.g. E-Z-Lift Chair, grab bars);
• VIP services such as housekeeping and grounds maintenance, and temporary intermediate care in a health care facility to allow the caregiver time for a vacation or to receive required health care; and/or
• Long-term care, such as temporary care in a health care facility. The length of time would vary according to the client's needs, the caregiver's needs and the availability of a respite bed.

When the eligible client is the caregiver, appropriate assistance may be provided to that person in order to prevent their health from deteriorating due to the strain of being a caregiver. However, the Department's legislated mandate is limited to providing care only to clients of the Department. Health care services may not be provided to a non-client, when that person is being cared for by a client.

Eligibility under the Veterans Independence Program

Eligibility Defined

For the purpose of this Review and in accordance with established criteria, “eligibility” will refer to the determination of to whom Veterans Affairs Canada funding of benefits for the Veterans Independence Program may be provided.

Determining Eligibility

Eligible Veteran pensioners, civilian pensioners and special duty service pensioners can access Veterans Independence Program services if:

• They are residents of Canada;
• Their war-related pensioned condition impairs their ability to remain self-sufficient at their principal residence without those services;
• The provision of those services would assist them to remain self-sufficient at their principal residence or the provision of that care is necessary for health reasons; and
• Those services are not available to them as an insured service under a provincial health care system.^{Footnote 10}

In general terms, the Veterans Independence Program services for which a Veteran pensioner, civilian pensioner or special duty service pensioner applies must be related to a pensionable condition. If, however, the program is not needed for the pensioned condition, such as hearing loss, an exception exists whereby the Veteran can qualify for benefits if the aggregate of all pensioned/awarded conditions is assessed as medium or seriously disabled. These categories are defined as:

Medium disabled is the term used to describe those Veteran pensioners or civilian pensioners whose extent of disability, in respect of the aggregate of all of their disability assessments under the Pension Act and the Canadian Forces Members and Veterans Re-establishment and Compensation Act is equal to or greater than 48 percent, but less than 78 percent.^{Footnote 11}

Seriously disabled, in relation to a client, means that the client's extent of disability, in respect of the aggregate of all of the client's disability assessments under the Pension Act and the Canadian Forces Members and Veterans Re-establishment and Compensation Act, is equal to or greater than 78 percent. Only clients with at least a portion of their disability related to service in the First World War, the Second World War, or the Korean War may be eligible for benefits as medium or seriously disabled.^{Footnote 12}

Veteran pensioners, civilian pensioners and special duty service pensioners are “… eligible to receive the VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

• They are resident in Canada;
• They are medium or seriously disabled; and,
• An assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.”^{Footnote 13}

According to the Veterans Health Care Regulations, a “Veteran” is eligible for Veterans Independence Program benefits if they are:

• Disability pension or award recipients who require VIP for their entitled conditions;
• Wartime pensioners who are seriously disabled (with disability entitlement at 78 percent or higher) or are medium disabled (48-77 percent) and who require VIP services for any health condition;
• Disability benefit recipients, who have multiple health conditions which, when combined with their VAC entitled condition places them at risk, may be provided VIP services for any health related need;
• War Veterans who qualify because of low income as established under the War Veterans Allowance Act;
• Recipients of Prisoner of War Compensation or Detention Benefits who are totally disabled;
• Overseas Service Veterans who have applied for care in the departmental facility (i.e. Ste. Anne's Hospital) or a contract bed and are not admitted because there is no vacancy within a reasonable distance of the community in which they reside;
• Canada Service Veterans who have a minimum of 365 days service, are over age 65 and income qualified; or
• Spouses, caregivers and survivors as per sections 16 and 16.1 of the Veterans Health Care Regulations.

In addition to the above program eligibility criteria, Veterans and civilians who apply for benefits must meet service eligibility requirements in order to qualify for certain benefits. Their eligibility for benefits will depend on having met the strict criteria attached to a given group of Veterans. Generally, eligible Veterans and civilians will fall into one of fourteen client groups that might set out the following criteria: minimum service requirements, specify certain wars, military campaigns or time frames, speak to affiliation with particular organizations or military units, require that the Veterans be in receipt of a certain pension, be assessed as frail, be income-qualified, have been a prisoner of war or any number of other qualifying requirements.

The creation of these client groups was the Government of Canada's response to the evolution of the various benefit programs that have emerged over time to address the specific health concerns of larger groups of clients, both military and civilian. While the intent of this approach was to facilitate the administration of the benefit programs by creating easily identifiable client groups and to provide a measure of consistency and fairness to end-users, the complexity of the eligibility grids and qualifiers have led to frustration in both the Veteran community and among Veterans Affairs Canada staff. It is also problematic for the Veteran who would like to self-assess, and for their caregivers and family members who could qualify for benefits themselves if the Veteran meets the requirements and qualifiers. The unintended consequence, however, is that when members of different client groups compare their eligibility requirements and the extent to which they can access benefits as compared to other groups, the perception of inconsistency and unfairness quickly rises to the surface.

An effective analogy is used in the Veterans Independence Program Audit to describe the evolution of the program and the expansion of the eligibility requirements to meet the demands of the various client groups, and the impact these changes have had on the program as a whole:

“During the interview process, the evaluation team was provided with a good analogy of the VIP: the house (VIP) was designed for a specific purpose (aging Veterans), and as rooms (eligibilities) have been added here and there over the years the foundation (relevance) of the house is no longer adequate to support all of the additions. The Department is now at a critical point where it is aware VIP is not a one-size fits all program for all recipients and it must determine what renovations it will do.”^{Footnote 14}

Given the numerous eligibility and qualifying criteria, determining a given client's eligibility for benefits becomes a difficult and frustrating task for Veterans Affairs Canada staff charged with this responsibility. The most consistent complaint from all stakeholder groups is that the eligibility criteria for the program are too stringent, complex and burdensome to interpret and administer consistently. A lack of flexibility in program and service eligibility requirements have had the unintended result of departmental staff trying to find workarounds or loopholes in order to provide gateway access to clients who would not normally be eligible for a certain benefits, such as long-term care. The Veterans Ombudsman is of the view that the time has come for former members of the RCMP to be formally recognized as Veterans.

Income and Means Testing

Eligibility for Veterans Independence Program benefits for certain groups of clients is significantly affected by an individual's income level, and by their spouse or common-law partner's income level. The majority of definitions under the Veterans Health Care Regulations include reference to the Pension Act, the Old Age Security Act and/or the War Veterans Allowance Act, all of which base their eligibility on income. For example, an “income-qualified Veteran” under the Veterans Health Care Regulations is defined as:

“… a Veteran referred to in any of paragraphs (a) to (g) of the definition “Veteran” who is in receipt of an allowance under the War Veterans Allowance Act or in respect of whom a determination has been made that the veteran would be eligible for such an allowance if the veteran or their spouse or common-law partner were not in receipt of, or eligible to receive, payments under the Old Age Security Act or similar legislation of another country.”^{Footnote 15}

The War Veterans Allowance Act authorizes the payment of income support to qualified Veterans and civilians who meet specific requirements related to war service, age or health, income and residence. An additional benefit may be paid on behalf of a spouse or common-law partner and for any dependent children. As well, a surviving spouse, a surviving common-law partner or orphan may qualify for a War Veterans Allowance by virtue of the deceased Veteran/Civilian's war service.

Frailty

In section 4.2, an exception to the pensioned condition eligibility rule was noted that enabled Veterans assessed as medium or seriously disabled to access benefits under the Veterans Independence Program. An additional exception to the pensioned condition requirement exists in that clients who are eligible for a pension or award for wartime service, special duty service or regular force service can access Veterans Independence Program services including intermediate care if they are assessed as “frail”.

“'Frailty' is defined as the occurrence of a critical mass of physiological changes that place the individual at risk of institutionalization, falls, injuries, illnesses or need for supervision or hospitalization that will result in prolonged impairment lasting at least twelve months. It is deemed that the pensioned condition is a contributing factor in these complex cases.”^{Footnote 16}

Examples of Eligibility Inconsistencies

Allied Veterans

Veterans Independence Program eligibility has been reinstated to certain Allied Veterans and their families. However, these changes have resulted in expanding the eligibility criteria, creating different eligibility standards for different groups of Veterans and their families.^{Footnote 18}

The net effect of the changes in eligibility is that some program benefits have been reinstated under the War Veterans Allowance Act to allow certain Allied Veterans of the Second World War and Korean War who meet residency requirements to access the Veterans Independence Program and long-term care benefits. These changes, quite understandably, create significant frustration for certain classes of Canadian Veterans who have chosen or are required to take up residence outside of the country, but have significant medical challenges that require the private purchase of costly supports. Unfortunately, similar legislation does not always exist in other countries, and these Veterans are faced with the harsh reality that if they had chosen to remain in Canada, and met the eligibility requirements, they would have been eligible for the same benefits as those now extended to foreign Allied Veterans living in Canada.

Canada Service Veterans^{Footnote 19}

To be eligible for benefits, Veterans Affairs Canada's eligibility criteria for Canada Service Veterans stipulate that they meet the following requirements:

1. A Veteran who served on full-time active service, other than service in a theatre of actual war, as a member of the Canadian Armed Forces or similar forces raised in Newfoundland; or
2. A Canadian merchant mariner, other than a merchant navy Veteran, and who;
   1. Served for a minimum of 365 days during any of the following periods, namely:
      • The period beginning on August 4, 1914, and ending on August 31, 1921; and,
      • The period beginning on September 1, 1939, and ending on August 15, 1945;
   2. Sixty-five (65) years of age or more; and,
   3. Satisfy the income requirement of an income-qualified Veteran.

For an Overseas Service Veteran to qualify for treatment benefits or Long-Term Care, they must meet the following requirements:

1. A Veteran who, on or before March 31, 1946, served during World War I or World War II in a theatre of actual war; or,
2. A Merchant Navy Veteran of World War I or World War II.

For the purpose of qualifying for Veterans Independence Program benefits, an Overseas Veteran is defined as:

1. A Veteran who served in a theatre of actual war during:
   1. World War I – specifically from August 4, 1914, to August 31, 1921; or
   2. World War II – specifically from September 1, 1939, to May 8, 1945, in respect of service in connection with operations in the European and Mediterranean theatres of war; and September 1, 1939, and August 15, 1945, in respect of service in connection with operations in the Pacific theatre of war;
2. A Merchant Navy Veteran of World War I or World War II.

The following clients are also considered Overseas Service Veterans:

1. A Veteran who was on service in a theatre of operations as a member of the Canadian Forces, including the special force; or,
2. A Canadian Merchant Navy Veteran of the Korean War; or
3. Effective January 1, 2010, an Allied Veteran described in paragraphs 37(4)(c.1) and (d.1) or subsection 37(4.2) of the War Veterans Allowance Act.

One issue that has attracted attention when reviewing the eligibility criteria for Canada Service Veterans is the need to have served at least 365 days. The 365-day requirement for Canada Service Veterans has never been fully understood and could be perceived as arbitrary when compared to other classifications of Veterans, such as Overseas Service Veterans who can qualify for benefits with less than 365 days of service. The effect of that requirement has been sufficient to deny benefits to some Canada Service Veterans who fall short of the 365-day requirement. Additionally, many Canada Service Veterans who were expecting to serve overseas were required in Canada during the war. They would likely have been ordered to remain in Canada primarily for specialized training or to protect Canadian sovereign territory. It is these types of conflicts that give rise to the perception that different classes of Veterans have been created within service-specific client groups.

Section 16 of the Veterans Health Care Regulations

On February 26, 2008, regulatory amendments to the Veterans Health Care Regulations (Section 16.1) were enacted. Grounds maintenance and housekeeping services provided under the Veterans Independence Program were extended to survivors of income qualified Veterans, income qualified civilians, or Veteran pensioners and Civilian pensioners of the Second World War or Korean War who were not in receipt of these services when the Veteran passed away. This new access was further restricted to survivors who were in receipt of the guaranteed income supplement under the Old Age Security Act.

The Veterans Health Care Regulations define “survivors” as:

• The adult individual who, immediately before the person died or, if the person died in a health care facility, immediately before the person was admitted into a health care facility;
  1. Was primarily responsible, without remuneration, for ensuring that care was provided to the person; and
  2. For a continuous period of at least one year, resided in the principal residence of the person and was maintained by the person.^{Footnote 20}

The effect of the Regulation is the following:

• If a Veteran was in receipt of both housekeeping and grounds maintenance services, the survivor will keep both services when the Veteran dies as per Section 16 of the Veterans Health Care Regulations.
• If the same Veteran did not receive housekeeping and grounds maintenance services, then the low-income survivor can apply and receive both services after the Veteran's death as per Section 16.1 of the Veterans Health Care Regulations.
• However, if the same Veteran was in receipt of one of the two services, then the low-income survivor can only keep the service that was in place at the time of death of the Veteran. The survivor can never receive the second service even if there is a need for it as per Section 16.1 of the Veterans Health Care Regulations.

The Office of the Veterans Ombudsman has concerns with this approach to eligibility in that it is difficult to understand why a survivor receiving one Veterans Independence Program service at the time of the Veteran's death would be denied access to the other service when a survivor who had none of the services can apply and receive both services after the Veteran's death. Additionally, one wonders why this expanded eligibility only targets Veterans of the Second World War and the Korean War.

Most importantly, access to Veterans Independence Program services should be based solely on needs, not on the nature of Veterans' military service and whether or not they were in receipt of housekeeping or grounds maintenance services prior to their death.

Accessibility under the Veterans Independence Program

Accessibility from a Client's Perspective

For the purposes of this Review, “accessibility” refers to the degree to which the services are available when needed by an eligible Veteran.

According to the Veterans Affairs Canada's 2010 National Client Survey, (a survey of all recipients of departmental programs) 85 percent of Veterans Independence Program recipients strongly agreed or agreed that they were able to find people to help them with the program's services that they need. A supporting file review conducted by the Program Performance Unit also found that 91 percent of recipients reported no difficulty accessing program services.^{Footnote 21}

Interviews with field staff conducted for the Evaluation of the Veterans Independence Program (VIP) – Final July 2011 found that there were some access to care issues present - mainly, in some rural and remote areas where there are fewer care options and provider availability.

Additionally, as part of the Department's evaluation, “issues related to remote access to services identified by field staff interviewed include the following:

• Few registered service provider options [e.g., Meals on Wheels, Merry Maids, etc.] and fewer options, if at all, in remote areas for specific specialist services and supports [e.g. adult day programs];
• Distance hinders access to home care and support services [mileage and minimum hour visit requirements impacts cost of care];
• More dependence is placed on family and informal caregivers instead of on registered service providers; and
• A barrier to service for some is that unregistered providers are fearful of signing claim forms due to potential tax implications.”^{Footnote 22}

The 2008 Canadian Home Care Association Portraits of Home Care report also discussed rural access to home care. The report identifies that access to home care is generally consistent between rural and urban settings, but service delivery and response times in some remote communities may be affected by an absence of service providers and by human resource challenges.^{Footnote 23}

Costs Associated with the Veterans Independence Program

Cost Defined

For the purposes of this Review, “cost” will refer to the funding required to maintain the program in its current mandate.

Program Recipients

As of December 2012, the total Veteran population was estimated at 712,700. Of this number, 211,675 Veterans, or 29.7 percent, including RCMP members and survivors, were clients of Veterans Affairs Canada, however, only 9.4 percent or 67,235 Veterans were clients of the Veterans Independence Program. An additional 75,208 survivors were clients of Veterans Affairs Canada, and 38,349 of the survivors were Veterans Independence Program clients.^{Footnote 24}

The total number of Veterans Independence Program clients has risen slightly (2 percent) from 2008 to 2012, primarily due to the expansion of the eligibility for survivors in that time period. Also contributing to the rise was the 58 percent increase in Canadian Forces Veterans accessing program services in the past 5 years, from 14,000 to just over 22,000 in 2012. These increases were almost completely offset by the decrease of War Service Veterans by 25 percent, from 60,000 in 2007 to 45,000 in 2012.

The trend of declining War Service Veterans offset by increasing numbers of survivors and Canadian Forces Veterans is expected to continue over the next five years. Because of this demographic shift, the overall composition of Veterans accessing Veterans Independence Program benefits is changing significantly. By 2015, the number of Canadian Forces Veterans accessing program benefits is expected to be larger than the number of War Service Veterans utilizing the Veterans Independence Program.^{Footnote 25}

Veterans Independence Program Costs

The total program cost for the Veterans independence Program during fiscal year 2011-2012 was $356.9 million. Four program elements consumed 96 percent of the total program costs:

• Housekeeping: $210.8 million (59 percent)
• Intermediate Care: $57.0 million (16 percent)
• Grounds Maintenance: $50.0 million (14 percent)
• Personal Care: $25.6 million (7 percent)

While program costs have been trending upwards since 2008, (a 17.7 percent increase in cost versus a two percent increase in the number of clients served over that time period), some of those cost increases can be attributed to the expansion of the eligibility criteria for certain groups of Veterans. Assuming eligibility criteria remain the same, program costs are forecasted to increase for fiscal year 2012-2013, then trend downwards, in concert with the shifting Veteran demographic. However, it should be noted that establishing a relationship between the number of clients and the cost of providing benefits could be misleading due to the ever-changing eligibility criteria, and the possibility of newer Veterans Independence Program clients accessing more costly benefits.

Cost Comparison between the Veterans Independence Program and the Long-Term Care Program

A review of per-client program costs for the Veterans Independence Program and the Long-Term Care Program illustrates the relative value to be realized by keeping Veterans in their homes as long as possible when it is medically and ethically safe to do so rather than housing them in long-term care facilities.

For the fiscal year 2011-2012, long-term care clients (intermediate and chronic care) under both the Long-Term Care Program and the Veterans Independence Program were numbered at 9,225. Together, long-term care costs came in at approximately $265 million for an overall average cost of $28,726 per client. However, when broken down into the two separate components of Veterans Affairs Canada's provision of long-term care, the 5,408 long-term care clients under the Long-Term Care Program (intermediate and chronic care) accounted for $208.5 million of the total cost or $38,554 on a per-patient basis, while the 3,429 Veterans Independence Program long-term care clients' (intermediate care only) total cost was only $57 million, or $16,594 per patient. (An additional 388 clients were residents of Ste. Anne's Hospital). However, the evaluation of per-patient costs must be measured against the fact that the length of patient stays differ from one Veteran to the next, as well as the reality that the cost of care varies widely from province to province. Nevertheless, when consideration is given to the fact that intermediate care under the Veterans Independence Program is carried out in long-term care facilities, the overall per-patient cost difference between the two programs is notable.

The total program costs for long-term care are forecast to trend downwards through to 2016-2017 to $242.2 million or by 8.6 percent; however, the per-patient cost difference between the Long-Term Care and Veterans Independence Program elements of long-term care is not expected to vary significantly.

For the Veterans Independence Program home care and health support program overall, the total client base is 105,584, made up of 67,235 War Service and Canadian Forces Veterans and 38,349 survivors and caregivers. The total program cost for the Veterans Independence Program for fiscal year 2011-2012 was $356.9 million, for an average cost of $3,380 per client. When broken down into the two main client groups, the War Service and Canadian Forces Veterans accounted for $265 million of the total cost, for a per client amount of $3,941, while the survivors and caregivers came in at a total program cost of $91.6 million or $2,389 per client.

Veterans Independence Program total program costs are also forecast to diminish through fiscal year 2016-2017 by 6.4 percent, from $356.9 million to approximately $334 million.^{Footnote 26}

While the Long-Term Care Program and the Veterans Independence Program were intended to address two different types of client needs, those requiring home care health supports and those requiring long-term care services, the reality is that they share responsibility for the provision of intermediate care services. Nevertheless, when taken on a per patient cost basis, it is clear from this analysis that the Veterans Independence Program provides excellent value for the intermediate care services it delivers, and, at the same time, achieves its goal of keeping Veterans living independently and with dignity in their homes for as long as possible in a cost-effective manner.

Changes to the Veterans Independence Program

Change in Eligibility Status for Serving Canadian Forces Members

Until 2013, certain serving Canadian Forces members receiving a Veterans Affairs Canada disability benefit were eligible to receive Veterans Independence Program services under the Veterans Health Care Regulations. Effective January 1, 2013, serving Canadian Forces members (excluding the Reserve Classes A and B^{Footnote 27}) are no longer eligible for a number of departmental programs including the Veterans Independence Program. The Department of National Defence has assumed primary responsibility for providing its members with required health care, home care and career transition services. Serving Canadian Armed Forces members who currently receive Veterans Affairs Canada's Veterans Independence Program services will continue to receive those services until their current contribution arrangement expires. The purpose of this change was to eliminate duplication and overlap in services between Veterans Affairs Canada and the Department of National Defence.

Payment Options for Housekeeping and Grounds Maintenance

Prior to 2013, services were paid through a third-party claims administrator. All services were paid based on the client's Contribution Arrangement. Once the services were approved there were three payment options:

1. Clients would be reimbursed for eligible expenses;
2. Registered service providers would bill directly for approved services; or
3. Funds would be advanced to the client on a prorated basis.

As of January 1, 2013, a semi-annual up-front payment is now provided for grounds maintenance and housekeeping services offered under the Veterans Independence Program. These up-front payments replace the current reimbursement process.

This change is being phased in as an individual client's Contribution Arrangement period expires. Until that time, they will continue to submit receipts as per the current process. In November 2012, clients were sent letters explaining the changes and were advised that they would be notified in writing two months in advance of the expiry of their current Benefit Arrangement period.

The grant calculation for housekeeping and grounds maintenance services were developed using a variety of data sources, including:

• Payments to registered service providers in the 2011-2012 fiscal year;
• Consultations with VAC staff who administer the VIP on the current approach to establishing rates for housekeeping and grounds maintenance;
• Telephone surveys with a representative sample of current VIP service providers to determine their approach to pricing services; and
• References to the Labour Market Information provided by Human Resources and Skills Development Canada for the wage component of the various housekeeping and grounds maintenance services.

It is important to note that due to the above considerations, Veterans Independence Program grants are not indexed^{Footnote 28} but reassessed to ensure that the grant amount is sufficient to meet the costs of the approved services. To ensure that Veterans Independence Program services, including housekeeping and grounds maintenance, are meeting clients' needs, Veterans Affairs Canada will conduct an annual follow-up with each client.

Clients are now responsible for managing their up-front payments and for paying their service providers directly. The client will be provided with letters that they may share with their service provider, identifying the date they will begin receiving the up-front grant payment. In addition, they may still use the service provider of their choice.

Other Veterans Independence Program services will not be affected. If receiving other program services such as personal care, the client or the service provider must submit receipts for those services.

Effect of the Changes

The Office of the Veterans Ombudsman has received the following contacts regarding the Veterans Independence Program grant system:

• 33 contacts requiring further information about the grant system;
• 35 complaints regarding the administration of the grant system (e.g. turn-around-times, the assessment process, etc.); and
• 22 complaints regarding the amount of the grant determination.^{Footnote 29}

As the changes mentioned above have only been recently implemented, and are being phased in as clients' Benefit Arrangement periods expire, it is too early to forecast with any certainty the effect they will have on administrative efficiency and effectiveness, the relationship with providers, or client satisfaction levels. Whether the changes impact the overall cost of the Veterans Independence Program remains to be seen.

Conclusion

This Review has examined the Veterans Independence Program and three important areas that affect the way services are delivered to and received by its clients: eligibility, accessibility and cost.

It is apparent from a national client satisfaction survey and a supporting file review that a large majority of Veterans Independence Program clients questioned had no difficulty accessing program services and were able to find the people who could provide them with the services they needed. This is a significant finding and a very positive performance measurement for a government program that services such a large number of Veterans, spouses and caregivers in so many regions of the country. However, the June 2013 edition of the Veterans Affairs Canada Facts and Figures Book on National Contact Centre Telephony Results shows that the number of queries for Veterans Independence Program calls represented 22.7 percent of all calls or 46,805 contacts in the first quarter of 2013-14. While being a positive indication of interest/demand, this high figure (more than double the number of calls for the next highest call area, i.e. disability benefits), may be attributable to the recent changes in program delivery (i.e. from the conversion of Veterans Independence Program contributions to grants for housekeeping and grounds maintenance).

The administration of the Veterans Independence Program, which provides benefits to such a wide variety of client groups, requires that the eligibility of each one of its clients be determined according to program and service criteria. It is understood that in the interests of fair treatment and equal access to benefits, clients must be categorized according to program or service requirements. However, these criteria must be reasonable in their application, seek to shed the complexity that has hindered their implementation, and be open to revision when situations arise that make it clear that the existing criteria are outdated, unfair, or inappropriate given the circumstances.

The complexity of eligibility criteria and program administration is also felt by intake officers at Veterans Affairs Canada, who are having difficulty navigating through and cross-referencing the eligibility grids associated with the program. They are also using a “gateway” approach to making certain benefits, such as intermediate care, available to clients who might not otherwise be eligible to access these benefits, but desperately need them.

It is clear that the Veterans Independence Program fills a need for eligible Veterans who wish to remain in their homes receiving assistance that allows them to maintain their health, quality of life, dignity and independence as long as possible. In order to continue to serve the best interests of Veterans in the years to come, however, the Program must be responsive to the issues that have been raised in this Review.

Annex 1 – Definition of Client Groups^{Footnote 30}

Allied veteran means a person who meets the service requirements described in subsection 37(4), (4.1) or (4.2) of the War Veterans Allowance Act, namely: any former member of

1. any of His Majesty’s forces,
2. any of the forces, other than resistance groups, of any of His Majesty’s allies,
3. any of the forces, other than resistance groups, of any power associated with His Majesty in World War I, or
   • c.1. any of the forces that took part in the Korean War who was domiciled in Canada at the time when he or she joined that force or at any time while a member of that force, and
4. served in a theatre of actual war during World War I or World War II,
   • d.1. served in a theatre of operations during the Korean War,
5. is in receipt of a pension for disability under the Pension Act in respect of service during World War I or World War II as those wars are defined in that Act,
6. has accepted a commuted pension in respect of service described in paragraph (e),
7. is, after death, declared to have been eligible for, or awarded, a pension described in paragraph (e) above, or
8. served in the United Kingdom during World War I.

An allied veteran is also any former member of any of His Majesty’s forces, or of any of the forces, other than resistance groups, of any of His Majesty’s allies in World War II, who served during that war, who resided in Canada for a total period of at least 10 years beginning on or after August 15, 1945, who has been honourably discharged or has been permitted honourably to resign or retire from one of those forces and who:

1. served in a theatre of actual war during that war;
2. is in receipt of a pension for an injury or disease incurred or aggravated during service in any such force during that war or is declared to have been eligible for, or awarded, such a pension subsequent to their death; or
3. has accepted a commuted pension.

An allied veteran is also any former member of any of the forces that took part in the Korean War and who served during that war, who resided in Canada for a total period of at least 10 years beginning on or after July 27, 1953, who has been honourably discharged or has been permitted honourably to resign or retire from one of those forces and who served in a theatre of operations during that war.

Canada Service Veteran means:

1. a veteran who served on full-time active service, other than service in a theatre of actual war, as a member of the Canadian forces or similar forces raised in Newfoundland; or
2. a Canadian merchant mariner, other than a merchant navy veteran, and who
   1. served for a minimum of 365 days during any of the following periods, namely:
      • the period beginning on August 4, 1914, and ending on August 31, 1921, and
      • the period beginning on September 1, 1939, and ending on August 15, 1945;
   2. is 65 years of age or more, and
   3. satisfies the income requirement of an income-qualified veteran.

Civilian means a person who meets the service requirements described in subsection 56(1) of the Civilian War-related Benefits Act, namely:

1. a person who served at sea in a ship of Canadian or Newfoundland registry during World War I or World War II for a period of at least six months, and made at least one trip through dangerous waters during that period of service;
2. a Canadian citizen, a Canadian national, or a British subject domiciled in Newfoundland at the commencement of his/her qualifying service who served at sea during World War I or World War II for a period of at least six months in a ship of United Kingdom registry or the registry of one of the countries allied or associated with His Majesty in either of those wars, and during that period of service made at least one trip through dangerous waters;
3. a Canadian citizen who served at sea in a ship of another country allied or associated with the United Nations during United Nations military operations in Korea for a period of at least six months, and during that period of service served at least twenty-eight days on such a ship within dangerous waters off the coast of Korea;
4. a person who was a member of the Corps of (Civilian) Canadian Fire Fighters for Service in the United Kingdom and served in a theatre of actual war during World War II;
5. a person who was a Canadian member of the Voluntary Aid Detachment of the British Red Cross during World War I and served in a theatre of actual war during World War I;
6. a person who, during World War II, served in a theatre of war under the auspices of the Canadian Red Cross Society or the St. John Ambulance Brigade of Canada, as welfare workers, nursing aids, ambulance or transport drivers, members of Overseas Headquarters Staff, or in any other capacity; or were selected by the Canadian Red Cross Society and served with the Scottish Ministry of Health as orthopaedic nurses or surgeons; or served outside Canada during the Korean War in a capacity similar to above;
7. a person who was a civilian member of Ferry Command and served in a theatre of actual war during World War II as air crew with Number 45 Wing of the Royal Air Force Transport Command, Number 45 Group of the Royal Air Force Ferry Command or the Atlantic Ferrying Organization;
8. a person who was a member of the Newfoundland Overseas Forestry Unit and served in a theatre of actual war during World War II, engaged in cutting pit props for coal production in the United Kingdom; or
9. a person who is in receipt of a pension under Parts I to X of the Civilian War-related Benefits Act or is declared to have been eligible for, or awarded, such a pension subsequent to the person’s death.

Civilian pensioner means a person who is entitled to a pension under any of Parts I to III or VI to X of the Civilian War-related Benefits Act, or the Civilian Government Employees (War) Compensation Order, namely:

1. Canadian Saltwater Fishers;
2. Auxiliary Services Personnel;
3. Newfoundland Overseas Forestry Unit;
4. Corps of (Civilian) Canadian Firefighters for service in the United Kingdom;
5. Air Raid Precautions Workers;
6. Voluntary Aid Detachment (World War I or II);
7. Overseas Welfare Workers (World War II or Korea); or
8. Ferry Command.

Flying accident pensioner means a person entitled to compensation under the Flying Accident Compensation Regulations for death or injuries sustained by that person.

Frail pensioner means a Veteran pensioner, a civilian pensioner, a special duty service pensioner, a military service pensioner, or a member or former member of the Canadian Forces who is entitled to a Disability Award who is considered to be at risk due to frailty. Frailty, in this instance, is defined as the occurrence of a critical mass of physiological conditions that place an individual at risk for falls, injuries, illnesses or the need for supervision or hospitalization. Frailty also results in a severe and prolonged impairment of function with little or no likelihood of improvement.

Income-qualified civilian means a civilian who:

1. is in receipt of an allowance under subsection 57(1) of the Civilian War-related Benefits Act; or
2. would be eligible for an allowance under that Act if the civilian or their spouse or common-law partner were not eligible for or in receipt of payments under the Old Age Security Act, or similar legislation of another country.

Income-qualified overseas service civilian means an overseas service civilian who is an income-qualified civilian.

Income-qualified veteran means a veteran who:

1. is in receipt of an allowance under the War Veterans Allowance Act; or
2. would be eligible for an allowance under the War Veterans Allowance Act were the veteran or their spouse or common-law partner not eligible for or in receipt of payments under the Old Age Security Act, or similar legislation of another country.

Merchant navy veteran means a person who meets the service requirements described in subsections 37(7.3) or 37(7.4) of the War Veterans Allowance Act, namely:

1. any person who served on board a Canadian ship while it was making a qualifying voyage (specific details can be found in subsection 37(7.3) of the War Veterans Allowance Act) during World War I or World War II, or any person domiciled in Canada who served on board an allied ship while it was making a qualifying voyage during World War I or World War II;
2. any person who, during World War I or World War II, made a trip by sea, land or air through or over a theatre of actual war for the purpose of proceeding to a Canadian ship in order to serve on a qualifying voyage or returning to Canada or the country of which the person was a citizen or national, after having made a qualifying voyage;
3. any person who, during World War I or World War II, served in a theatre of actual war as a member of a Canadian manning pool;
4. any person domiciled in Canada who, during World War I or World War II, made a trip by sea, land or air through or over a theatre of actual war for the purpose of proceeding to an allied ship in order to serve on a qualifying voyage, or returning to Canada, after having made a qualifying voyage;
5. any person domiciled in Canada who, during World War I or World War II, served in a theatre of actual war as a member of an allied manning pool or was a distressed mariner;
6. any person who is in receipt of a pension, has accepted a commuted pension, or is declared eligible for, or is awarded, a pension subsequent to the person’s death for an injury or disease incurred or aggravated during service as a Canadian merchant mariner of World War I or Canadian merchant mariner of World War II within the meaning of section 21.1 of the Pension Act;
7. any person who, at any time during the period from June 25, 1950 to July 27, 1953, served on board a Canadian ship while in prescribed waters (specific details can be found in subsection 37(7.4) of the War Veterans Allowance Act) off the coast of Korea; or
8. any person who is in receipt of a pension, has accepted a commuted pension, or is declared eligible for, or is awarded, a pension subsequent to the person’s death for an injury or disease incurred or aggravated during service as a Canadian merchant mariner of the Korean War within the meaning of section 21.1 of the Pension Act.

Military service pensioner^{Footnote 31}means a person who is entitled to a pension under the Pension Act for a disability related to military service that was not active service in World War I or World War II, service in a theatre of operations, or special duty service.

Newfoundland Special Award pensioner means a person who was not entitled to a pension in accordance with the terms of the union of Canada and Newfoundland but was recognized by the Canadian government as entitled to the continuation of an award paid before that union in respect of a disability incurred during war time service.

Overseas service civilian means a person who meets the service requirements described in paragraph (e), (f), (g), (h) or (i) of subsection 56(1) of the Civilian War-related Benefits Act, namely:

1. a person who served in a theatre of actual war during World War II as a member of the Corps of (Civilian) Canadian Fire Fighters for Service in the United Kingdom. (These individuals served in the United Kingdom assisting the National Fire Service combat fires caused by enemy air raids and bombing.);
2. a person who
   1. served in a theatre of actual war during World War II as an overseas welfare worker. (These individuals served, under the auspices of the Canadian Red Cross Society or the St. John Ambulance Brigade of Canada, as welfare workers, nursing aids, ambulance or transport drivers, members of Overseas Headquarters Staff, or in any other capacity; or were selected by the Canadian Red Cross Society and served with the Scottish Ministry of Health as orthopaedic nurses or surgeons.); or
   2. served outside Canada during the Korean War in a capacity similar to paragraph i) above;
3. a person who served in a theatre of actual war during World War II as a civilian member of Ferry Command. (These individuals were employed by the Air Ministry of the United Kingdom, and served as air crew with Number 45 Wing of the Royal Air Force Transport Command, Number 45 Group of the Royal Air Force Ferry Command or the Atlantic Ferrying Organization.);
4. a person who served in a theatre of actual war during World War II as a member of the Newfoundland Overseas Forestry Unit. (These individuals were engaged in cutting pit props for coal production in the United Kingdom.); or
5. a person who served in a theatre of actual war during World War I as a Canadian member of the Voluntary Aid Detachment of the British Red Cross. (These individuals were selected by the St. John’s Ambulance Brigade and sent to the United Kingdom to assist the Voluntary Aid Detachments of the British Red Cross.)

Overseas service veteran (OSV)

For the purpose of qualifying for treatment benefits and long-term care, an OSV is defined as:

1. a veteran who, on or before March 31, 1946, served during World War I or World War II in a theatre of actual war; or
2. a Merchant Navy Veteran of World War I or World War II.

For the purpose of qualifying for Veterans Independence Program benefits, an OSV is defined as:

1. a veteran who served in a theatre of actual war during:
   1. World War I – specifically from August 4, 1914, to August 31, 1921; or
   2. World War II – specifically from September 1, 1939, to May 8, 1945, in respect of service in connection with operations in the European and Mediterranean theatres of war; and September 1, 1939, and August 15, 1945, in respect of service in connection with operations in the Pacific theatre of war;
2. a Merchant Navy Veteran of World War I or World War II;

The following clients are also considered Overseas Service Veterans:

1. a Veteran who was on service in a theatre of operations as a member of the Canadian Forces, including the special force;
2. a Canadian Merchant Navy Veteran of the Korean War; or
3. effective January 1, 2010, an Allied Veteran described in paragraphs 37(4)(c.1) and (d.1) or subsection 37(4.2) of the War Veterans Allowance Act.

Prisoner of War means a prisoner of war of Japan or a prisoner of war of another power.

A Prisoner of War of Japan is:

1. a person who served during World War II in the Canadian Forces;
2. a person who served during World War II in the Allied Forces and was domiciled in Canada at the time of enlistment;
3. a merchant navy veteran; or
4. a civilian

who was a prisoner of war of Japan or was engaged in evading capture by or in escaping from the Japanese.

A Prisoner of War of another power is:

1. a person who served during World War I or II in the Canadian Forces;
2. a person who served during World War I or II in the Allied Forces and was domiciled in Canada at the time of enlistment;
3. a merchant navy veteran; or
4. a civilian

who was a prisoner of war of any power, excluding Japan, that was engaged in military operations against His Majesty’s forces or allies, or who was engaged in evading capture by or in escaping from such a power.

A Prisoner of War of another power is also a person who served in the Canadian Forces during military operations subsequent to World War I or II and who, while serving, was a prisoner of war of any power or was engaged in evading capture by or in escaping from any power; and a Canadian merchant navy veteran of the Korean War who was a prisoner of war of any power or was engaged in evading capture by or in escaping from any power.

Red Cross pensioner means a Red Cross worker who is entitled to a pension under an order in council made pursuant to the National Defence Act as a result of that service. The order in council was made subsequent to a memorandum of agreement between Her Majesty and the Canadian Red Cross Society on October 17, 1952.

Reserve Force Member means a member:

1. of the Supplementary Reserve Force;
2. on a period of Class A Reserve Service, as described in article 9.06 of the Queen’s Regulations and Orders for the Canadian Forces; or
3. on a period of Class B Reserve Service, as described in article 9.07 of the Queen’s Regulations and Orders for the Canadian Forces for a period of 180 days or less.

Seriously disabled, in relation to a client, means that the client’s extent of disability, in respect of the aggregate of all of the client’s disability assessments under the Pension Act and the Canadian Forces Members and Veterans Re-establishment and Compensation Act, is equal to or greater than 78%. (Only clients with at least a portion of their disability related to service in WWI, WWII,, or the Korean War may be eligible for benefits as seriously disabled.)

Special duty service pensioner^{Footnote 32} means a person who is entitled to a pension under the Pension Act for a disability attributable to or incurred during special duty service.

Veteran means:

1. a person who was on active service during World War I or World War II as a member of the naval, army or air forces of Canada or of similar forces raised in Newfoundland;
2. a person who was on service in a theatre of operations as a member of the Canadian Forces, including the special force;
   • b.1. a person who was on active service during the Korean War as a member of the special force;
3. a special operator who is deemed to be a veteran pursuant to section 3 of the Special Operators War Service Benefits Act;
4. a supervisor who is deemed to be a veteran pursuant to section 3 of the Supervisors War Service Benefits Act;
5. an allied veteran within the meaning of subsection 37(4), (4.1) or (4.2) of the War Veterans Allowance Act;
   • e.1. a person described in paragraphs 64(1)(a) or (b), 65(1)(a) or (b), or 66(1)(a) or (b) of the Pension Act.
6. a Canadian merchant mariner of World War I, World War II or the Korean War;
7. a person who is an allied veteran within the meaning of paragraph 37(4)(b) of the War Veterans Allowance Act, as that paragraph read immediately before February 27, 1995
   1. in respect of whom a determination has been made, on or at any time before that day, that the person is or has been an income-qualified veteran, or
   2. who, on or at any time before that day, has submitted a request that has at any time been approved for
      1. adult residential care pursuant to section 17.1;
      2. Veterans Independence Program services pursuant to section 18;
      3. adult residential care, intermediate care or chronic care; or
      4. the cost of chronic care in a community facility pursuant to paragraph 22(4)(b);
8. a former member of His Majesty’s forces, or of any of the forces, other than resistance groups, of any of His Majesty’s allies or powers associated with His Majesty in World War I or World War II, who
   1. served during either of those wars during the period set out in paragraph 37(10)(b) or (c), as the case may be, of the War Veterans Allowance Act;
   2. has resided in Canada for a total period of at least 10 years;
   3. does not meet the Canadian domicile requirements of subsection 37(4) of that Act; and
   4. served in a theatre of actual war as defined in subsection 37(8) of that Act, or receives a pension for an injury or disease incurred or aggravated during service in any such force during either of those wars or accepted a commuted pension.

Veteran pensioner is a veteran, referred to in any of paragraphs (a) to (g) of the definition "veteran," who is entitled to a pension under the Pension Act for a war-related pensioned condition.

Annex 2 – Summary of Eligibility by Client Group^{Footnote 33}

Eligibility for Health Care Programs – Allied Veterans

Veterans Independence Program

Allied Veterans of World War II who either satisfy a pre-war Canadian domicile criterion or are grandfathered are eligible to receive VIP services to the extent that the services are not available as insured services under a provincial health care system if they satisfy the definition of an income-qualified Veteran, and:

1. they are resident in Canada; and
2. an assessment indicates that the provision of these services will assist them to remain self-sufficient at their principal residence, or the provision of that care is necessary for health reasons.

Allied Veterans of World War II who satisfy the post-war Canadian residence requirement, and Allied Veterans of the Korean War (both pre-war domicile and those with 10 years post-war residence) are eligible to receive VIP services to the extent that the services are not available as insured services under a provincial health care system if:

1. they are resident in Canada;
2. they satisfy the definition of an income-qualified veteran; and
3. an assessment indicates that the provision of these services will assist them to remain self-sufficient at their principal residence, or the provision of that care is necessary for health reasons

Allied Veterans of World War II who satisfy the post-war Canadian residence requirement, and Allied Veterans of the Korean War (both pre-war domicile and those with 10 years post-war residence) who satisfy the definition of an overseas service veteran are eligible to receive all VIP services to the extent that the services are not available as insured services under a provincial health care system if:

1. they are resident in Canada;
2. they have exceptional health needs;
3. they have insufficient income to enable them to pay for those services or that care; and
4. an assessment indicates that the provision of the VIP services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Clients eligible under exceptional health needs are required to pay the amount of their assessable income that exceeds the WVA income factor toward the cost of their VIP services. Those receiving intermediate care are also required to pay up to the maximum accommodation and meal rate.

Eligibility for Health Care Programs – Canada Service Veterans

Veterans Independence Program

Canada Service Veterans are eligible to receive all VIP services to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that the provision of these services will assist them to remain self-sufficient at their principal residence, or the provision of that care is necessary for health reasons.

Individuals who meet the service and age requirements of Canada Service Veterans, but do not meet the income requirements, are eligible to receive all VIP services to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they are resident in Canada;
2. they have exceptional health needs;
3. they have insufficient income to enable them to pay for those services or that care; and
4. an assessment indicates that the provision of these services will assist them to remain self-sufficient at their principal residence, or the provision of that care is necessary for health reasons.

Clients eligible under exceptional health needs are required to pay the amount of their assessable income that exceeds the WVA income factor toward the cost of their VIP services. Those receiving intermediate care are also required to pay up to the maximum accommodation and meals rate.

Eligibility for Health Care Programs - Civilian Pensioners

Veterans Independence Program

Civilian Pensioners are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that their war-related pensioned condition impairs their ability to remain self-sufficient at their principal residence without those services, and the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Civilian Pensioners are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada;
2. they are seriously disabled; and,
3. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Civilian Pensioners are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada;
2. they meet the criteria of 'frail'; and
3. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Detention Benefit Recipients

Veterans Independence Program

Detention Benefit recipients are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that the services or that care is not available as insured services under a provincial health care system, if:

1. they are resident in Canada;
2. they are totally disabled, whether by reason of military service or not; and
3. an assessment indicates that the provision of these services will assist them to remain in their principal residence or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Entitled to a Disability Award^{Footnote 34} (Regular and Reserve Force Services)

Veterans Independence Program

Former members or reserve force members who are entitled to a disability award in respect of special duty service are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, if the services or care is neither available to them as former members or reserve force members of the Canadian Forces nor available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that the disability for which they are entitled to a disability award, impairs their ability to remain self-sufficient at their principal residence without those services, and the provision of the services would assist them to remain self-sufficient at their principal residence; or
3. the provision of the services would assist them to remain self-sufficient at their principal residence or the provision of the care is necessary for health reasons.

Former members or reserve force members who are entitled to a disability award in respect of special duty service are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, if:

1. the services or care is neither available to them as former members or reserve force members of the Canadian Forces nor available to them as an insured service under a provincial health care system;
2. they are resident in Canada;
3. they meet the criteria of 'frail'; and
4. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Entitled to a Disability Award in Respect of Special Duty Service^{Footnote 35}

Veterans Independence Program

Former members or reserve force members who are entitled to a disability award in respect of special duty service are eligible to receive VIPservices of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, if:

1. not available to them as former members or reserve force members;
2. not available to them as an insured service under a provincial health care system;
3. they are resident in Canada;
4. an assessment indicates that their war-related pensioned condition impairs their ability to remain self-sufficient at their principal residence without those services; and
5. the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Former members or reserve force members who are entitled to a disability award in respect of special duty service are eligible to receive the VIP services of home care, ambulatory health care and home adaptations, or intermediate care in a community facility, other than a contract bed, if:

1. not available to them as former members or reserve force members;
2. not available to them as an insured service under a provincial health care system;
3. they are resident in Canada;
4. they meet the criteria of 'frail'; and
5. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Income - Qualified Overseas Civilian

Veterans Independence Program

Income-qualified Overseas Service Civilians (who are 65 years of age or more) are eligible to receive all VIP services to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that the provision of these services will assist them to remain self-sufficient at their principal residence, or the provision of that care is necessary for health reasons.

Eligibility for Health Care Programs – Income Qualified Veterans

Veterans Independence Program

Income-qualified Veterans (who are 65 years of age or more) are eligible to receive all VIP services to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that the provision of these services will assist them to remain self-sufficient at their principal residence, or the provision of that care is necessary for health reasons.

Eligibility for Health Care Programs – Medium Disabled Veteran & Civilian Pensioners

Veterans Independence Program

Veteran Pensioners or Civilian Pensioners who satisfy the criteria to be recognized as Medium Disabled are eligible to receive the services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Military Service Pensioners

Veterans Independence Program

Military Service Pensioners are eligible to receive the VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system or as former members or reserve force members of the Canadian Forces, if:

1. they are resident in Canada; and
2. an assessment indicates that their pensioned condition impairs their ability to remain self-sufficient at their principal residence without those services, and the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Military Service Pensioners are eligible to receive the VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada;
2. they meet the criteria of 'frail'; and
3. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Overseas Service Civilians

Veterans Independence Program

Overseas Service Civilians are eligible to receive all VIP services to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they are resident in Canada;
2. they have exceptional health needs;
3. they have insufficient income to enable them to pay for those services or that care; and
4. an assessment indicates that the provision of the VIP services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Clients eligible under exceptional health needs are required to pay the amount of their assessable income that exceeds the WVA income factor toward the cost of their VIP services. Those receiving intermediate care are also required to pay up to the maximum accommodation and meal rate.

Eligibility for Health Care Programs – Overseas Service Veterans

Veterans Independence Program

Overseas Service Veterans eligible for intermediate care or chronic care in a departmental facility or in a contract bed are also eligible to receive home care, ambulatory health care and home adaptation services under the VIP, to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they have applied to the Minister for admission to a departmental facility or contract bed, and are not admitted because there is no vacancy in a departmental facility or contract bed within a reasonable distance of the community in which they normally reside;
2. they are resident in Canada; and
3. an assessment indicates that the provision of those service will assist them to remain self-sufficient at their principal residence.

The preceding paragraph does not apply to those Allied Veterans being recognized effective January 1, 2010, as these individuals are precluded from receiving long-term care in a departmental facility or contract bed.

Overseas Service Veterans are eligible to receive all VIP services to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they are resident in Canada;
2. they have exceptional health needs;
3. they have insufficient income to enable them to pay for those services or that care; and
4. an assessment indicates that the provision of the VIP services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Clients eligible under exceptional health needs are required to pay the amount of their assessable income that exceeds the WVA income factor toward the cost of their VIP services. Those receiving intermediate care are also required to pay up to the maximum accommodation and meal rate.

Eligibility for Health Care Programs – Primary Caregivers

Veterans Independence Program

A primary caregiver is entitled to housekeeping services and/or maintenance of the grounds that the client was receiving under the Department of Veterans Affairs Act at the time the client died or began residing in a health care facility, if:

1. the primary caregiver is assessed within one year after the earlier of the client's death or the client's admission into the health care facility or presents evidence relating to their health condition during that period on the basis of which as assessment can be made;
2. the assessment and all subsequent assessments indicate that the provision of the services are necessary for health reasons and to assist the primary caregiver to remain self-sufficient at their principal residence;
3. the primary caregiver is a resident of Canada; and
4. the services are not available to the primary caregiver as insured services under a provincial health care system or a private insurance policy.

Eligibility for Health Care Programs – Prisoner of War

Veterans Independence Program

Prisoners of War are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed to the extent that these services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada;
2. they are totally disabled, whether by reason of military service or not; and
3. an assessment indicates that the provision of those services will assist them to remain in their principal residence or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Seriously Disabled Clients

Veterans Independence Program

Veteran Pensioners or Civilian Pensioners who satisfy the criteria to be recognized as "Seriously Disabled" are eligible to receive the services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Special Duty Service Pensioners

Veterans Independence Program

Special Duty Service Pensioners are eligible to receive VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, if:

1. the services or care is not available to them as an insured service under a provincial health care system;
2. they are resident in Canada;
3. an assessment indicates that their war-related pensioned condition impairs their ability to remain self-sufficient at their principal residence without those services; and
4. the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Special Duty Service Pensioners are eligible to receive the VIP services of home care, ambulatory health care and home adaptations, or intermediate care in a community facility, other than a contract bed, if:

1. the services or care is neither available to them as former members or reserve force members of the Canadian Forces nor available to them as an insured service under a provincial health care system;
2. they are resident in Canada;
3. they meet the criteria of 'frail'; and
4. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Eligibility for Health Care Programs – Survivors

Veterans Independence Program

The survivor is eligible to receive housekeeping services and grounds maintenance, if:

1. an assessment and all subsequent assessments indicate that the provision of the services is necessary for reasons related to the health of the survivor and to assist the survivor to remain self-sufficient at their principal residence;
2. the survivor is in receipt of the guaranteed income supplement under the Old Age Security Act or is approved for the Disability Tax Credit under section 118.3 of the Income Tax Act;
3. the services are not available to them as insured services under a provincial health care system or a private insurance policy;
4. the survivor is not eligible to receive any services as a primary caregiver under Section 16 of the VHCR; and
5. the survivor is a resident of Canada.

Eligibility for Health Care Programs – Veteran Pensioners

Veterans Independence Program

Veteran Pensioners are eligible to receive the VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada; and
2. an assessment indicates that their war-related pensioned condition impairs their ability to remain self-sufficient at their principal residence without those services, and the provision of those services will assist them to remain self-sufficient at their principal residence or that the provision of care is necessary for health reasons.

Veteran Pensioners are eligible to receive the VIP services of home care, ambulatory health care, and home adaptations, or intermediate care in a community facility, other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if;

1. they are resident in Canada;
2. they are medium or seriously disabled; and
3. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Veteran Pensioners are eligible to receive the VIP services of home care, ambulatory health care and home adaptations, or intermediate care in a community facility other than a contract bed, to the extent that those services or that care is not available to them as an insured service under a provincial health care system, if:

1. they are resident in Canada;
2. they meet the criteria of 'frail'; and
3. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Veteran Pensioners are eligible to receive all VIP services to the extent that the services are not available to them as insured services under a provincial health care system, if:

1. they are resident in Canada;
2. they have exceptional health care needs;
3. they have insufficient income to enable them to pay for those services or that care; and
4. an assessment indicates that the provision of those services will assist them to remain self-sufficient at their principal residence, or that the provision of care is necessary for health reasons.

Clients eligible under exceptional health needs are required to pay the amount of their assessable income that exceeds the WVA income factor toward the cost of their VIP services. Those receiving intermediate care are also required to pay up to the maximum accommodation and meal rate.

Annex 3 – Type I, II and III Health Needs Definitions^{Footnote 36}

Type I Health Need - means the need of a person for personal care and supervision on a continuing basis, where the person is ambulant or independently mobile but has
decreased physical or mental faculties.

Type II Health Need - means the need of a person for personal care on a continuing basis under the supervision of a health professional, where the person has a functional disability, has reached the apparent limit of recovery and has little need for diagnostic or therapeutic services.

Type III Health Need - means the need of a person for personal care and for diagnostic, nursing and therapeutic services provided by a health professional on a continuing basis, where the person is chronically ill or has a functional disability and the acute phase of the illness or disability has ended, whether or not the status of the illness or disability is unstable.

Annex 4 – VIP Program Recipients and Forecast to FY 2016-2017

Recipients – Actual

[Source: Veterans Affairs Canada Facts and Figures Book 2012]

Recipients – Forecast

[Source: Veterans Affairs Canada Facts and Figures Book 2012]

Annex 5 – VIP Program Expenditures and Forecast to FY 2016-2017

Expenditures – Actual

[Source: Veterans Affairs Canada Facts and Figures Book 2012]

Expenditures – Forecast

[Source: Veterans Affairs Canada Facts and Figures Book 2012]

Annex 6 – Long-Term Care and VIP Clients, Expenditures under both the Long-Term Care Program and the Veterans Independence Program (Intermediate Care) Forecast to FY 2016-2017

Veterans Affairs Canada – Long-Term Care Clients by Program and Fiscal Year (Actual* and Forecast)

[Source: Department of Veterans Affairs, 2012]

Veterans Affairs Canada – Long-Term Care Expenditures by Program and Fiscal Year (Actual* and Forecast)

[Source: Department of Veterans Affairs, 2012]