Canadian Association of Occupational Therapists. Senate Subcommittee on Veterans Affairs

Transcription

1 Canadian Association of Occupational Therapists Submission to the Senate Subcommittee on Veterans Affairs Occupational Therapy: Supporting successful transitions to civilian life Wednesday, October 24, 2012

2 Executive Summary Canadian Association of Occupational Therapists Submission to the Senate Subcommittee on Veterans Affairs Occupational Therapy: Supporting successful transitions to civilian life Wednesday, October 24, 2012 The Canadian Association of Occupational Therapists (CAOT) is committed to working with Veterans Affairs Canada (VAC) and the Department of National Defence (DND) to support access to meaningful and effective interventions that will allow veterans to successfully transition to civilian life. There are many opportunities to advance this goal through cost-effective physical and mental health interventions. This submission to the Senate Subcommittee on Veterans Affairs outlines the contributions of occupational therapy in achieving the goal of successful transition to civilian life for veterans. Using evidence from the Survey on Transition to Civilian Life, a report on Post-traumatic Stress Disorder and the Mental Health of Military Personnel and Veterans, and supporting documentation on the economic costs of illness and cost effectiveness of occupational therapy interventions, this submission identifies opportunities where occupational therapists can work to improve overall outcomes for veterans in the areas of health and well-being, as well as improved labour market transitions for those most impacted by illness, injury and disability from their service with the Canadian military. Occupational therapists in Canada are highly educated health professionals that bring a wide range of expertise to the field of rehabilitation science. Whether it is working with clients with complex chronic disease, chronic pain, physical or mental illness, injury or disability, occupational therapists focus on getting clients back on track to be the best a person can be using interventions to improve functional outcomes with both the body and the mind. For military personnel, occupational therapy interventions can bring meaningful change to support successful transitions to civilian life. Based on the evidence outlined in this paper, CAOT recommends the use of occupational therapy services to VAC and New Veterans Charter (NVC) to support the needs of veterans as they transition to civilian life. In particular, occupational therapy services should be expanded to support the following: 1. Case management to coordinate services for veterans in the areas of physical and mental illness, injury and disability. 2. Occupational performance analysis/functional capacity evaluation to identify needs, progress and outcomes for veterans in their labour market transitions. 3. Occupational therapy services to improve transitions to family and civilian life, including education and support for families to better understand the needs of veterans impacted by physical and mental illness. Occupational therapy is an essential health service that enables Canadians to maximize their productivity, reduce lifestyle restrictions and avoid unnecessary dependency. CAOT believes it is important to stress that timely action is required to ensure that veterans are receiving the right supports and services both as active members of the Canadian Forces, as well as after their release. Taking action by employing the right mix of health service professionals and providing access to services for physical and mental illness, injury and disability is necessary to address the immediate concerns of veterans. The result will be improved overall health and well-being which can be measured through increased success in transitions to civilian and family life, improved productivity and labour market engagement.

3 Introduction Occupational therapy is the art and science of facilitating participation in everyday living that includes active engagement in meaningful activities or occupations. Occupational therapists consider everything that a person does throughout their day as occupation. For military personnel, this not only includes the responsibilities related to preparing for, engaging in or returning from active engagement, but all the activities of daily living. The origin and development of the occupational therapy profession is closely tied with the military. In 1915, the Military Hospitals Commission was created to address the needs of returning injured soldiers. Ward Occupation Aides facilitated the re-entry of veterans within their communities and assisted them in identifying occupations to allow them to participate in their social constructs. Almost a century later, the activities related to occupational therapy have evolved, focusing on a balance of functional outcomes with client-centred goals, but the profession has maintained close ties to its original goals: to empower military personnel and their families to fully engage in the occupations that they want and need to do. Today, occupational therapy is an essential health service that enables Canadians to maximize their productivity, reduce lifestyle restrictions and avoid unnecessary dependency. A sense of well-being and meaning in one s daily occupations is an important determinant of health and an effective means to reduce health care costs. For both active military and veterans, occupational therapists are involved in services that span the continuum of care ranging from mental health to physical rehabilitation and community re-integration. The role of occupational therapists in the military continues to provide a vital service in helping soldiers, veterans and their families engage in their meaningful occupations and identify the right balance between their social, environment and personal needs. The Canadian Association of Occupational Therapists (CAOT) is a national member-based association representing occupational therapists in Canada. With over 13,000 practicing occupational therapists in Canada, CAOT provides leadership and is committed to supporting access to occupational therapy for military personnel and veterans to support rehabilitation from illness, injury and disability, as well as facilitate the successful transition to civilian life. This submission to the Senate Subcommittee on Veterans Affairs will outline the contributions of occupational therapy in achieving the goal of successful transition to civilian life and identify opportunities to improve overall outcomes for veterans in the areas of health and well-being, as well as improved labour market transitions for those most impacted by illness, injury and disability from their service with the Canadian military. What we know In January 2011, Veterans Affairs Canada (VAC) and the Department of National Defence (DND) released the first report on the Survey on Transition to Civilian Life (Thompson et al, 2011). The survey was commissioned to better understand how former Canadian Forces members are doing after they leave the military. The survey was conducted by Statistics Canada in 2010 as a national telephone survey of 4,800 former Canadian Forces Regular Force members who actively served in the military and were released from service between 1998 and 2007 (Veterans Affairs Canada, n.d.). Prior to the release of the survey results, there was limited evidence of the experiences of former Canadian military as they transitioned to civilian life. The objective of the survey was to develop a better understanding of experiences by measuring the health, disability and determinants of health of former Page 1

4 Regular Force personnel after their release from service (Thompson et al, 2011). A great deal of information can be gleaned from the survey, but some of the most important findings relate to the current state of health and well-being, as well as access to benefits to support transition to civilian life. Some of the key findings include: Veterans released from service between had worse health, disability and determinants of health status than the general Canadian population The majority of veterans during this period reported an easy adjustment to civilian life, and those with reported difficulties had accessed assistance from VAC Those not receiving benefits from VAC on average had higher rates of some chronic health conditions and disability, and significant rates of attributing both to military service 91-92% of VAC clients reported at least one physical health condition diagnosed by a health professional and between 40-60% report one mental health condition New Veterans Charter (NVC) clients had the worst health status and reported higher rates of unemployment following release Overall, the 2011 report found the majority of veterans (62%) had an easy transition to civilian life, but there are some challenges, particularly for those who have physical and mental health diagnoses. For both VAC and NVC clients, as well as non-clients, there exists unmet health and mental health needs and issues with the reach or availability of programs. It is for this reason that CAOT believes there is a great opportunity for occupational therapists to contribute to the development of effective programs and services that will support veterans in their daily functioning and occupations. The Library of Parliament s Jean-Rodrigue Paré authored another report in 2011 entitled Post-traumatic Stress Disorder and the Mental Health of Military Personnel and Veterans. This report identified that approximately three quarters of the veterans taking part in VAC rehabilitation programs following their release for medical reasons are suffering from mental health problems (Paré, 2011: 9, Veterans Affairs Canada, 2010). Mental health issues, particularly conditions such as Post-traumatic Stress Disorder (PTSD), are increasingly understood as areas in need of attention and appropriate health interventions. As identified in Paré s report, the demand for psychiatric care is increasing and, despite efforts to establish a network of specialized external clinics, VAC is struggling to meet the current demand for services (Paré, 2011). Other issues identified by Paré include the risks associated with operational stress injuries. Operational stress injury is a term used by the military and police for mental health disorders related to posttraumatic stress (Paré, 2011). Evidence gathered by the Department of Veterans Affairs in Canada indicates that there are many risks associated with untreated operational stress injury. While posttraumatic stress is a treatable mental illness, when the symptoms become chronic there is a significant increase in the severity of symptoms (Paré, 2011). These symptoms range from absenteeism and unemployment to homelessness and suicide (Paré, 2011). It is the responsibility of the Government of Canada to provide the necessary supports and services to Canadian Forces personnel and veterans, not only as active members of the service, but to respond to their health needs following their service. While VAC and NVC have been developed to respond to illness, injury and disability, the results of the 2010 Survey on Transitions to Civilian Life indicate that not all veterans are receiving the care they need, and for those receiving benefits, there is room to improve their health, well-being and labour market outcomes. When examining the incidence of mental health concerns in military personnel and veterans, the issues of PTSD or operational stress injuries create a Page 2

5 new layer of complexity for how to respond to the health needs of veterans, and support their transition to civilian life. How occupational therapy can help Human beings need occupation to give meaning and purpose to their lives. Occupational therapists, the primary service providers of occupational therapy, have advanced education and understand the effects of factors that are currently challenging the recovery of military personal and veterans of the Canadian Forces. Meaningful and relevant occupation is important to achieving the goals of rehabilitation, recovery, health and well-being; however, as service members leave their role in the military their lives and their occupations can change dramatically. It is for this reason that occupational therapy is an essential service to support those with operational stress injuries, poor health or mental health, and physical or cognitive disabilities resulting from service. Occupational therapists can enable veterans to maximize their functional outcomes by enabling participation in meaningful and relevant, as well as therapeutic occupations. Using a recovery-oriented philosophy, occupational therapists develop client-centred interventions that focus on engagement in meaningful activities. These activities can help to bridge the strengths and abilities of veterans developed through the military. Unfortunately, there remain gaps in the availability of services and limited scope to the interventions that support successful reintegration of veterans to civilian life. The following outlines some of the areas that occupational therapy can support veterans through a scope of interventions from simple to complex. Post-traumatic Stress Disorder and Driving Driving is an essential life skill which enables individuals to be engaged in the many activities available to them within their environment. Driving behaviours learned for combat situations may impact driving safety in a civilian context. The presence of post-traumatic stress disorder (PTSD), and other possible comorbidies, further impact post-deployed military personnel in their transition to civilian driving. Occupational therapists can assist in managing combat related symptoms and behaviours, and provide support and strategies to facilitate veterans return to safe driving. One simple intervention to support the needs of veterans in safe driving may be the use of GPS to provide interactive guidance and direction to a veteran who may experience stress, anxiety and short-term memory difficulties, especially in an unfamiliar environment. Physical injury and disability Military personnel are exposed to a wide range of experiences and environments, including situations that can lead to multiple traumas and serious physical injuries. For veterans who have experienced a traumatic physical injury, they require complex care and support for successful rehabilitation and recovery. For a soldier who has lost a limb, occupational therapists do far more than modify home environments and prescribe aids for daily living. Occupational therapists work with clients to maximize independence and basic living skills by developing client-specific goals for physical and cognitive recovery (Hareyan, 2007). For a soldier who has lost an arm, this can include supporting the client in their own self-care so they are able to bathe independently, learn how to button a shirt with a prosthetic arm and learn new techniques for cooking and preparing food. Occupational therapists also enable clients to identify goals and strategies that allow them to re-engage in social activities and paid employment. These aspects of living are critical to community reintegration. Page 3

6 Labour Market Transition Occupational therapists work with both employees and employers to assess how people perform tasks within their surroundings, and then suggest changes, both at the individual and the organizational level. The goal of these assessments is to achieve optimum function in and out of the workplace. In the context of the military or Veterans Affairs, the skills and expertise provided by occupational therapists provided an ideal framework to support the recovery of soldiers whether it is returning to work in the Canadian Forces or changing careers and seeking employment as a civilian. Considering the evidence which indicates high levels of unemployment for veterans receiving benefits through the NVC, it is imperative to develop a strategy that supports veterans in their recovery to provide opportunities to return to work. Examining the economic evidence around the cost of health services, unemployment, absenteeism and presenteeism associated with physical and mental illness, there are huge opportunities to not only reduce the costs to society, but engage veterans in occupations that will utilize their strengths and abilities, in turn creating a more robust and productive workforce. Supporting evidence Occupational therapists are highly educated and regulated health professionals who promote health and well-being by enabling individuals, groups and communities to participate in occupations that give meaning and purpose to their lives (CAOT, 2009). With an increased interest in the economics of health care, many studies indicate that occupational therapy offers solutions that are both cost-effective and respond to other pressures on the health system (Institute for Work and Health, 2007; Denis et al, 2011; MacDonald, 2006; Loisel et al, 2002; McGregor and Pentland, 1997). In the broader health system, the evidence of cost effectiveness indicates clear opportunities for occupational therapists to use their expertise and full scope of practice to improve client care as a health promotion expert or primary care practitioner in case management, chronic disease management, injury prevention, care-giver education, intervening at the point of health crisis or hospitalization to prevent hospitalizations, shorten hospital stays, provide community or care-giver support to prevent readmission, work in rehabilitation, and help clients redefine or better understand changing occupation in illness and injury to improve productivity and quality of life. Given the evidence released by the Centre for Addictions and Mental Health which suggests mental health costs employers and the Canadian economy approximately $51 billion a year in lost productivity and health care costs there is an argument to be made for proactive interventions for veterans to ensure they are able to successfully transition into civilian life and the labour market (Dewa et al, 2008). This argument can be supported by other evidence on Past-Traumatic Stress Disorder among military and veterans which indicates when the impacts of an operational stress injury are treated in a timely and appropriate manner, full remission may result in 30% to 50% of cases (Richardson, 2010). This evidence supports the case for VAC and NVC clients who are dependent on services to support life and living from moderate health or activity limitations to complex health and mental health problems, and the consequences of managing daily life with these challenges. Occupational therapists are also able to measure functional outcomes and improvements in a range of occupational areas and levels of development using standardized assessment tools such the Canadian Occupational Performance Measure (COPM). The COPM was originally developed in 1991 and is now an internationally recognized tool based on an individualized, client-centred assessment to measure Page 4

7 functional outcomes (Law et al, 1991). The tool is administered by occupational therapists and used to detect change in a client's self-perception of occupational performance over time. Because of the individualized nature of the tool, it works with the goals, values and perceptions of the client and is flexible in its administration to ensure that it is compatible with the culture and needs of military personnel and veterans in their rehabilitation and efforts to either return to work in the military or transition to civilian life. The COPM has also undergone extensive research in many different occupational therapy practice situations and the majority of clients and therapists indicate that the measure is easy to administer, taking just minutes (Law, et al, 1991). Recommendations CAOT recommends the use of occupational therapy services to VAC and NVC to support the needs of veterans as they transition to civilian life. More specifically, occupational therapy services should be expanded to support the following: 1. Case management and service delivery to coordinate the care of veterans in the areas of physical and mental illness, injury and disability. 2. Occupational Performance Analysis/Functional Capacity Evaluation to identify needs, progress and outcomes for veterans in their labour market transitions. 3. Occupational therapy services to improve transitions to family and civilian life, including education and support for families to better understand the needs of veterans impacted by physical and mental illness. Conclusion The goal of CAOT is to work with VAC and DND to support access to meaningful and effective interventions that will allow veterans to successfully transition to civilian life. There are many opportunities to advance this goal through cost-effective physical and mental health interventions. CAOT also believes it is important to stress that timely action is required. There has been some public criticism of the inadequacy of benefits provided by the NVC and the gaps in services available to military personnel and veterans. Taking action by employing the right mix of health service professionals and providing access to services for physical and mental illness, injury and disability is necessary to address the immediate concerns of veterans. The result will be improved overall health and well-being which can be measured through increased success in transitions to civilian and family life, improved productivity and labour market engagement. Page 5

8 References Canadian Association of Occupational Therapists (2009). Practice Profile for Support Personnel in Occupational Therapy. Ottawa: Authors. Retrieved April 30, 2012 from Denis, J.-L., Davies, H.T.O., Ferlie, E., Fitzgerald, L., and McManus, A Assessing Initiatives to Transform Healthcare Systems: Lessons for the Canadian healthcare system. Canadian Health Services Research Foundation Series on Healthcare Transformation: Paper 1. Ottawa, ON: Canadian Health Services Research Foundation. Dewa, CS et al A new population-based measure of the burden of mental illness in Canada, Chronic Diseases in Canada. Hareyan, A Occupational Therapy: Restoring Lives of Wounded Warriors. Cited on-line at October 16, Institute for Work and Health Is it worthwhile investing in health and safety programs? Sharing best evidence: Highlights of a systematic review. Institute for Work and Health. Law, M, Baptiste, S, Carswell, A, McColl, MA, Polatajko, H, Pollock, N Canadian Occupational Performance Measure. Toronto, ON: CAOT Publications ACE. Loisel, P., Lemaire, J., Poitras, S., Durand, M.-J., Champagne, F., Stock, S., Diallo, B., and Tremblay, C Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine, 59, MacDonald, D Occupational Therapists: An environmental scan of the economic literature. Ottawa, ON: CAOT Publications ACE. McGregor, K., and Pentland, B Head injury rehabilitation in the UK: An economic perspective. Social Science and Medicine, 45(2), Paré, JR Post-traumatic Stress Disorder and the Mental Health of Military Personnel and Veterans. Library of Parliament: International Affairs, Trade and Finance Division, Parliamentary Information and Research Service. Richardson, D Presentation to the House of Commons Standing Committee on Veterans Affairs. 3 rd Session, 40 th Parliament. Thompson, J, MacLean, MB, Van Til, L, Sweet, J, Poirier, A, Pedlar, D, Adams, J, Horton, V, Sudom, K, Campbell, C Survey on Transition to Civilian Life: Report on Regular Force Veterans. Veterans Affairs Canada and National Defence. Veterans Affairs Canada. n.d. Transition to Civilian Life Survey. Cited on-line October 16, 2012 at Page 1