CF members serve voluntarily, and as such, willingly accept the statutory authority of the chain of command to compel members to perform any lawful duty at any time. This includes accepting the risks to health and life of performing hazardous duties or being placed in harm’s way.
- Duty of Honour: The profession of Arms in Canada
As illustrated by Canadian Forces (CF) operations carried out over the past twelve or more years, the conditions under which military duty is performed are often physically and psychologically demanding, and sometimes extremely dangerous. Injuries due to military operations or accidents, naturally occurring diseases, and even the normal wear and tear of military service are not uncommon. When these adversities occur, Canada’s men and women in uniform need to feel confident that the Government of Canada will provide the services necessary to restore them to health and optimal functioning, that their families’ needs will be met during a period of convalescence that can be long and difficult, and that they will receive the assistance necessary to make new lives for themselves should they be unable to resume military service.
In 1998 the Standing Committee on National Defence and Veterans Affairs stated in its report on quality of life in the CF that the nation has a moral commitment to military personnel in recognition of the sacrifices they make and the services they render, a commitment based on five concrete principles, one of which specifically concerns ill and injured military personnel:
That suitable recognition, care and compensation be provided to veterans and those injured in the service of Canada.
Given the above, I am pleased to introduce a comprehensive framework, which organizes the programs and services offered to CF ill and injured members and their families into an integrated system of care that ensures they receive the care and support they require through the successive phases of recovery, rehabilitation, and reintegration.
It has been said that the manner in which a society or institution treat their most vulnerable members is a hallmark of their quality. In the military, none are more vulnerable than those who are injured or become ill. For them, the duty and responsibility to care for our own resides especially with the leadership of the CF, DND, and VAC. I assume my share of that duty and responsibility willingly and completely.
Chief of the Defence Staff
Our comprehensive approach to care calls upon all current systems of support to serve a common objective, and takes into account all phases of treatment and rehabilitation – from the onset of illness or injury to the return to work. This approach requires the integration and coordination of services available through the military health care system, the military administrative and social support system, and the transition and veteran support system managed by Veterans Affairs Canada (VAC). Our concept of care envisages coordinated, integrated and consistent delivery and administration of benefits and services during the three stages that members must navigate following injury or illness: recovery, rehabilitation, and reintegration into military service or return to civilian life.
There is significant overlap between the three phases (treated in greater detail in Parts II, III, and IV) as ill or injured members move from acute recovery to longer-term clinical, physical, mental and vocational rehabilitative support, often preparing all the while to reintegrate (see Figure 1).
Upon discharge from an acute-care facility, the patient begins the sometimes lengthy rehabilitation phase, which includes clinical and non-clinical service and program support for that patient and his or her family. In the reintegration phase, the member either resumes military duties in the Regular Force or Primary Reserve, enrols in the Cadet Organizations Administration and Training Service (COATS) or Canadian Rangers, or transitions to civilian life.
The health services treatments and items (medical and dental) provided to CF personnel at public expense are listed in the CF Spectrum of Care document, which covers the needs associated with the full continuum of care, from prevention and promotion, through treatment, and on to rehabilitation. The document also states that all military personnel, regardless of where they serve, have access to a standard of service comparable to that of other Canadians.
Our primary goal is to return personnel to duty in their military occupation as soon as medically possible. Success depends on a number of factors, including the nature and severity of the illness or injury, the speed and intensity of the intervention, patient morale and commitment, the quality of case management and the efficacy of available treatments.
If an ill or injured member of the forces cannot resume employment in a particular occupation, our secondary goal is to retain the member in an alternate military occupation that falls within the parameters of the universality of service policy (U of S) and is commensurate with his or her abilities and interests.
The CF are committed to upholding the U of S principle according to which all CF personnel are liable to perform general military duties and common defence and security duties, and not only those of their military occupation or occupational specialty. The minimum operational standards associated with this principle are the following: a CF member must be physically fit, employable without significant limitations, and deployable for operational duties. U of S is a necessary and equitable approach to preserving the CF’s trained effective strength and operational capacity. As a matter of CF policy, personnel from the Canadian Rangers and the COATS are not subject to U of S minimum operational standards unless they are attached, seconded, or transferred on consent to the Regular Force or Primary Reserve. 1
When an injury or illness results in a permanent, medically based employment limitation (MEL) that breaches U of S, our goal is to prepare the individual for transition either to the COATS or Canadian Rangers, which are sub-components of the Reserve Force, or to civilian life. An administrative review to determine suitability for continued service will not be initiated until a reliable prognosis of health or functional capacity has been made by the military medical authority. Injured or ill members of the CF who are employable on a full-time basis, within their limitations, may be retained in the Regular Force or Primary Reserve, subject to service requirements, for up to three years. Severely injured or ill CF members who are not employable on a full-time basis but are assessed by the medical authority to have complex transition needs may also be provided up to three years of transition support by the CF. 2
When military personnel are released with MELs, VAC assumes responsibility for their reintegration into civilian life, in coordination with the provinces that have responsibility to provide health care to veterans and their families. VAC support is provided under a complementary framework based on the Canadian Forces Members and Veterans Re-Establishment and Compensation Act of 2006. Also known as the New Veterans Charter (NVC), the Act tailors a broad package of benefits, services and programs to the needs of individual CF veterans and their families.
Our framework of care concept is supported by five pillars that illustrate how the integrated, equitable, responsive, and well communicated delivery of health care and support services meets the unique needs of ill and injured CF personnel, veterans and their families through the phases of recovery, rehabilitation and reintegration.
The care of ill and injured CF personnel and their families is a Government of Canada commitment which is fulfilled through a whole-of-government approach. The duty and responsibility to care for our current and former members reside especially with the leadership of the CF, the DND, and VAC.
In the CF, the Chief of Military Personnel (CMP) is the functional authority for health services, casualty 3 support and administration, physical fitness and sports, career management, family services, and compensation and benefits. To coordinate and facilitate the best possible integrated support services for all injured and ill CF personnel, the management of medical and support care has been centralized under CMP authority. This ensures that health services are fully integrated with both military family and casualty support services. Under the authority of the CMP, the Canadian Forces Health Services (CFHS) are responsible for providing full-spectrum, high-quality health services to Canada’s military forces wherever they serve. Where services cannot be provided directly by the CF, the CFHS ensure equitable and consistent care for all ill or injured CF members through Memoranda of Understanding (MOU) with civilian care facilities located across the provinces and territories: the CFHS also address the purchase of direct health services.
At VAC, the Assistant Deputy Minister, Program, Policy and Communications (ADM PPC), and the Assistant Deputy Minister, Service Delivery (ADM SD) share the responsibilities for the care and support responsibilities of medically released CF veterans and their families. Harmonization of upcoming and existing policies, programs, and services across institutional boundaries, including transition protocols and information exchange, is achieved through the VAC-DND Steering Committee, which is co-chaired by CMP and the ADM SD, as well as through subordinate inter-departmental committees and working groups. The purpose of the VAC-DND Steering Committee is to provide an overarching governance structure for identifying and managing the joint priorities of DND and VAC as well as strategic direction and guidance to all working groups that may be required to move joint priorities forward. Together these two organizations ensure that current and former CF members, veterans and their families receive the care and support they need to ensure their well-being.
Owing to the broad geographic distribution of CF units, military personnel are not necessarily injured nor do they become ill near a CFHS facility. The CFHS and its facilities maintain close working relationships with provincial health care partners and allies to ensure that no matter where personnel are located, they will have access to the best available care. Regardless of where members first present themselves for care, they will eventually be cared for by a CF health care team. The core team is the Care Delivery Unit (CDU) of the CFHS clinic. This multidisciplinary team of health professionals ensures that the delivery of care is well coordinated between the military and civilian health care professionals that are required to meet the needs of the patient. Support is concurrently offered to family members of the patient throughout the trying times they are faced with.
CF health and support services are closely connected to their provincial and territorial counterparts to ensure seamless care for all ill or injured CF personnel. Consistency of care is assured through common case management procedures, MOUs and our ongoing interaction with national, provincial, territorial and local health authorities, professional licensing bodies, private sector organizations, and civilian training centres.
Military, civilian, as well as government institutions such as VAC, work together to coordinate and facilitate the best possible integrated support services for all injured and ill CF personnel and veterans, as they do for their families and the families of deceased members. The development of effective relationships and strategic partnerships between CF clinics and civilian health care providers who function in corresponding areas of responsibility is a valuable component of integrated health services delivery. These relationships facilitate the following: early identification and mobilization of civilian resources necessary to meet and successfully respond to unique CF casualty requirements, transfers to and between hospitals, CFHS oversight of care during acute recovery and rehabilitation, access to the full spectrum of specialist care, maintenance of clinical competencies among CFHS personnel and maintenance of trans-regional flexibility.
The CFHS oversight of the member’s care plan and their engagement with civilian health care providers continue throughout the recovery, rehabilitation and reintegration phases, thereby ensuring an ongoing and tangible link to the military community.
CF personnel have access to the same standard of health care and publicly funded benefits and services as other Canadians have access to under their provincial health care plans. The Canadian Forces Spectrum of Care document describes these benefits and services and sets one standard of health care for all CF personnel.
The Directorate of Casualty Support Management (DCSM) is a national organization that provides oversight and coordination leading to the standardized and harmonized application of policies and the delivery of multifaceted programs that entrench support for the CF community, serving and retired. To ensure consistent and equitable administration of military casualties, the CF have established sites across the country that provide a comprehensive, decentralized and integrated network of casualty support under the centralized command and control of CMP. Designated the Joint Personnel Support Unit (JPSU), its regional centres have a capability which is locally responsive to Base/Wing commanders, while linking to other military and civilian service providers and incorporating their services. In this manner, the JPSU is able to offer ill and injured CF personnel the dedicated oversight of command and control in addition to its consistent and integrated suite of non-clinical support services across the country.
To provide command and control tailored to the needs of seriously ill or injured members, Regular Force and Primary Reserve personnel who have a medical condition that precludes their returning to normal duty in a timely manner may be posted to the JPSU and assigned to one of its components – an Integrated Personnel Support Centre (IPSC). They might also be transferred to the Service Personnel Holding List (SPHL) in locations where an IPSC has not yet been stood up.
IPSCs across the country are managed by eight regional JPSU command elements. A number of factors influence the choice of an IPSC, such as the need for specialized treatment or physical rehabilitation, its proximity to a designated health care facility, the location and availability of family support and the location of the member’s parent unit.
The JPSU and its constituent parts deliver a set of core capabilities in a one-stop service approach that gives access to a network of comprehensive and consistent support for CF personnel and their families. 4 It also maintains a national tracking system that facilitates regular contact with all injured and ill personnel, whether serving or released, so as to ensure that needs are addressed, required services provided, appropriate benefits received, questions answered and referrals made. The casualty tracking co-ordinator of each IPSC maintains contact with members until such time as they return to unrestricted duty or, for those who are medically released, until they are capable of living independently or indicate that they no longer require support.
A career management cell at National Defence Headquarters (NDHQ) dedicated to ill and injured military personnel ensures appropriate and consistent management of those who are undergoing rehabilitation and who will either be retained in service indefinitely or for a period during which they are subject to employment limitations. The management cell is responsible for liaising with the career managers of other occupations to identify positions in which ill and injured members can be employed within the limits of their illness or disability. This management cell also co-ordinates return-to-work (RTW) employment, training, and postings of these members. To ensure that ill and injured personnel are aware of the personnel-management policies and procedures that may affect them, and to see to it that their employment needs are being met, the specialized career management cell provides annual personal briefings and interviews at each IPSC.
Through the coordination and facilitation of integrated support services, the JPSU and its IPSCs provide access to available benefits and family services, allowing ill and injured CF personnel and their families to focus on recovery and reintegration.
Continuous Improvement (CI) is an ongoing effort to improve products, services and processes through regular and periodic evaluation and review. Improvement may be either incremental over time or point-in-time comprehensive. As an important part of military culture, CI is an integral part of operational doctrine in which the lessons-learned process prescribes the collection and analysis of data, along with the direction and implementation of changes that identify and address deficiencies.
The CF continuously evaluate the effectiveness of policies, programs, and services in support of ill and injured personnel and their families, responding to deficiencies identified by stakeholders and making changes to improve service delivery.
As for Continuous Quality Improvement (CQI), it is fundamental to an effective health care culture; practitioners continually acquire new knowledge and skills to update practice, improve health care outcomes and adapt to changing circumstances.
Deployed elements of the CFHS are subject to after-action reporting and lessons learned processes that contribute to quality improvement in clinical and operational practices, organizational structure, casualty-care training and related protocols, medical equipment and force generation. The working groups of the Standing Committee on Operational Medicine Review (SCOMR) analyze the input so that combat medical training can be adjusted accordingly without delay.
The CFHS also contribute to research and analysis of the personal protective equipment worn by injured CF personnel, with the goal of increasing the survivability of others.
At home, CFHS clinics and headquarters participate in the health care accreditation program of Accreditation Canada. Through a cyclical process of self-assessment and external peer review, client service performance is compared to national standards of excellence so as to identify strengths and opportunities for improvement. The process is attuned to the distinct CF culture, organization and operational requirements and allows us to examine all aspects of health care, from patient safety and ethics to staff training and partnering with the community.
Further, the CFHS have enhanced their approach to periodic health assessments. More frequent and comprehensive monitoring of chronic-disease risk factors and screening for mental health problems have led to earlier diagnoses of disease and increasing the likelihood of disease being cured or managed successfully.
While individual feedback on the adequacy of existing services helps to identify problems in particular policies or procedures, systemic issues are more readily identified through broad-based analyses. To this end, the CF regularly host symposia with a view to gathering information on casualty support, family issues, and to share lessons learned and best practices.
The CI cell in the JPSU ensures that various mechanisms are in place to monitor the support services available to CF personnel who were injured, medically released or who became ill while serving, and the services available to their families. The analyses of various input, such as national casualty tracking, monthly reports, staff assistance visits as well as client and supervisor satisfaction questionnaires, lead to continuous and incremental improvements in the efficiency and effectiveness of its services.
The Lessons Learned cell uses a knowledge management system that allows employees to share observations on service delivery, policies, protocols and other activities; it also allows for feedback, identifying issues and lessons learned during the analysis of the gathered information, and putting to use knowledge gained through past experiences. This cell verifies, stores, disseminates and uses lessons learned in support of organizational objectives.
It is essential that military personnel be made aware of the services available to them and their families. The CF maintain robust internal and external communications that cover the full scope of health services, administrative support programs and services, as well as transition and veteran support services. These are summarized in a DCSM annual publication entitled Death and Disability Benefits, Programs and Services: A Guide for Serving and Former Canadian Forces Personnel and Their Families.
Ensuring the effectiveness of casualty support programs and services delivery to the people who need them depends to a significant degree on the general awareness of CF members and their families of what is available and, more importantly, it depends on how they can get support when they need it.
Through the use of the Intranet and Internet, as well as that of printed publications and the media, the JPSU CI communications cell conveys to the widest audience the improvements, new protocols and results of identified service gaps and implemented solutions, along with client feedback. The communications cell also aims to educate CF personnel on the administrative programs and policies available during all phases of recovery, rehabilitation and reintegration to military service, or transition following release for all injured and ill CF personnel, former personnel and their families, and the families of the deceased.
Unit commanders and supervisors also require a basic understanding of the framework of care if they are to adequately discharge their responsibilities for the well-being of their subordinates. Formal information and training seminars for administrative staff, articles in military newspapers and journals, handbooks and guides, toll-free numbers, Web sites and other electronic and paper-based products are all part of the CF effort to effectively spread the message.
Public awareness is equally important, if for no other reason than to reassure Canadians that their sons, daughters, brothers, sisters, husbands, wives, friends, and neighbours who have been entrusted to the custody and care of the CF are being well looked after. That trust is the basis of public support for the CF.
Although CF personnel can become ill or suffer injury any time, any place, our approach to care and treatment is location-dependent during the recovery phase. CF personnel on non-operational duties who become ill or injured in Canada will generally obtain treatment at military medical clinics during working hours and through civilian health care providers after normal working hours.
Should the illness or injury occur on deployed operations in Canada or abroad, initial treatment is generally administered by CF or allied health care providers. If the patient is in Europe or will be repatriated through Europe, the senior medical authority for Canadian Forces Support Unit Europe (CFSU(E)) liaises with the attending medical team and CF medical officers in Canada to arrange for an aeromedical evacuation and coordinates repatriation as soon as the patient is stable. If the patient requires further hospital care, a Casualty Reception Team (CRT) 5 organizes his or her arrival in Canada, then transfer and admission to hospital. Attention is given to choosing a health care facility that can meet the patient’s clinical needs, and is close to family support.
Regardless of where an illness or injury occurs, the CF help each patient to navigate a great many issues; on the one hand, the medical, financial and administrative matters that must be sorted out, and on the other hand, the benefits and career implications that they must understand.
A Casualty Management Team (CMT) 6 is formed to oversee and coordinate the medical, psychosocial and spiritual care of CF patients with complex medical situations. A complex case would be that of a patient with health concerns and medical employment limitations which are likely to extend beyond three months. Coordination of care and support would be indicated for a complex case, as would education about his or her illness or disability, and the programs and services that are available.
The CMT assists both patient and family by coordinating their access to multiple clinical services, thereby alleviating the overwhelming individual challenge of accessing care and support during medical treatment and recovery from physical, cognitive or psychological trauma.
The CMT assumes responsibility for the patient upon admission to the civilian health care facility and continues after discharge throughout physical and vocational rehabilitation, or until the patient is transitioned out of the CF. Responsibility for case management is then transferred to VAC.
The Assisting Officer (AO) 7 is a key member of the CMT. Appointed by the Commanding Officer (CO) of the member’s home unit, the AO is a vital link between the CF and the patient as well as his or her family. The AO provides sensitive but constructive support, assists with legal and financial affairs – in particular, casualty benefits and administration – and liaises with organizations and individuals to obtain their help in meeting the patient’s administrative needs.
A CF member who becomes ill or is injured in Canada will normally present to a designated CFHS Centre during working hours, or be taken to a local emergency room if need be. After hours, on weekends, and during holidays, a CF member requiring emergency care or treatment will report to a local hospital or civilian care centre. Patients in recovery will continue to be followed by military care providers, but they will receive care from wherever the necessary expertise is located, be it a military or civilian establishment.
When a CF member becomes ill or is injured in an operation, he or she will receive immediate medical attention from first responders, and will then be transferred to a role 1, 2 or 3 facility 8 depending on the severity of the illness or injury. The patient who recovers sufficiently to return to duty will not be repatriated to his or her home base in Canada. However, should the patient be very seriously ill or injured, he or she will receive emergency care and, once stabilized, will be transferred if need be to a more sophisticated medical facility, such as the Landstuhl Regional Medical Centre. Medical personnel of the CF liaise closely with the allied attending medical team so as to keep the patient’s family updated and determine the timing of his or her return to Canada and the medical services that will be required at the receiving hospital.
Through consultation with formation surgeons and medical experts in Canada, the receiving medical facility is selected. Once the clinical capabilities necessary to treat the patient’s illness or injury and destination have been determined, the aeromedical evacuation is initiated as is casualty-specific planning with the receiving civilian hospital to solidify care arrangements.
After the patient is repatriated to Canada and admitted to a health care facility, patient-care management remains the same regardless of where the illness or injury began.
Acute care will continue until the patient is stabilized and ready for transfer to another medical facility or to the member’s home.
Most civilian facilities have formal discharge planning processes for patients who require ongoing post-discharge medical support. CF medical personnel and relevant health professionals are engaged in this process from the outset as the coordination of equipment, transportation requirements and home modifications necessary to support the patient at home may require significant lead time to coordinate. CFHS management continues to play a lead role for convalescing patients who must contend with complex requirements. If reintegration into the CF is not an option, transition planning will start as soon as possible during the course of the patient’s hospitalization. However, the next step is rehabilitation, regardless of whether a member reintegrates into the CF or transitions to civilian life.
CF physical rehabilitation services have been expanded to provide an internal capability to address a sharp spike in musculoskeletal (MSK) injuries and meet the rehabilitation needs of seriously injured CF members. The CF have recognized that early and effective physical rehabilitation intervention can prevent many injuries not only from re-occurring or worsening, but more importantly, from becoming chronic conditions which might entail the development of permanent limitations on employment and other activities.
Head injuries, including concussion and traumatic brain injury (TBI), can co-occur with MSK injuries. Concussion and mild TBI can result in the need for physical rehabilitation, which may be in connection with cognitive or other neurological rehabilitation. These are conducted under the supervision of mental health specialists, occupational therapists and allied health professionals. Because the risk of Operational Stress Injury (OSI) 9 requires particular vigilance, a mental health specialist is a key member of the team supervising a patient’s extensive physical rehabilitation.
Several programs contribute to the CF’s physical rehabilitation capability. Foremost among these is the CF Physical Rehabilitation Program (CFPRP), which is designed to ensure that injured CF personnel have access to and receive the optimal level of physical rehabilitation consistent with their injuries and available therapies.
Seven base health services centres across the country, augmented by physiotherapists and occupational therapists, have been designated and set up as centres of military rehabilitation expertise (Esquimalt, Edmonton, Shilo/Winnipeg, Petawawa/Ottawa, Valcartier, Gagetown and Halifax). Each centre has a formal partnership with one or more civilian rehabilitation facilities, ensuring that patients receive the appropriate services, at the appropriate time. The CFPRP has established links with DCSM, VAC and other CF rehabilitation services to ensure that patients receive comprehensive patient care in accordance with standardized policies, procedures and protocols. 10 For example, the Adaptive Fitness Program of the Personnel Support Programs (PSP) includes a network of Regional Adapted Fitness Specialists who work with the personnel of the CFPRP and casualty management personnel to assist in the conditioning of ill and injured personnel.
The Soldier On Program, another physical rehabilitative service offered by the CF, provides ill and injured personnel and former personnel the resources and opportunities to attain and maintain a healthy, active lifestyle through physical fitness and sport. Managed in partnership with the Canadian Paralympic Committee (CPC), this program serves to enhance the necessary progression from physical rehabilitation to physical activity and sport, increasing the chances for injured or ill CF personnel to achieve functional independence and return to duty.
Studies show that the probability of a return to full employment or duty following convalescence decreases markedly as the time away from work increases. The CF RTW Program, a CF vocational rehabilitation program, which is made available to ill or injured personnel, has been designed to help restore their physical and mental health through reintegration into the workplace and progressive resumption of regular duties.
As soon as medically possible, personnel enter into a transitional employment period in which the duration, intensity and scope of duties that they must carry out are typically modified in accordance with their capabilities. Each RTW plan is developed jointly by the treating medical officer, the ill or injured member, and the member’s supervisor. Regional adapted fitness specialists and physical exercise specialists also participate in the RTW teams. They are specialists in adaptive physical activity who collaborate with casualty-management and rehabilitation-program personnel in the conditioning of ill and injured personnel.
Peer support is an important component of the CF vocational rehabilitation process. For example, the Injured Soldier Network offers serving CF members who have suffered severe illness or physical injury the possibility of being matched with peer partners who are likewise severely ill or injured serving members, but who have regained control of their situation. The program’s aim is to support and encourage recovering ill and injured CF personnel in their efforts towards meeting the U of S operational standards and returning to duty.
The psychological fitness of military personnel is an essential component of operational effectiveness, and the provision of mental health care 11 is a key part of the fundamental obligation of the CF to promote the well-being of their personnel. This challenge has become all the more pressing in recent years given the increased reporting rates of mental health disorders among CF military personnel and the heightened risk of operational stress injuries among members returning from deployed operations. Accordingly, the focus on psychological fitness and the compassionate treatment of psychological injuries as soon as they occur are key elements of CF rehabilitative services.
Owing to the broad scope of mental fitness, the CF take an interdisciplinary harmonized approach to the wellness of their members. This approach focuses equally on education, prevention and intervention, and it includes physiological medicine and health care, along with social work, counsellors, chaplains, peer and social support, recreation and community service.
Maintaining the mental fitness of CF personnel requires that in-garrison resources ensure mental health promotion, prevention, and treatment on a daily basis. The CF must also have a capability to support operations directly through pre-deployment, deployment, and post-deployment clinical services.
When returning home from theatre, military personnel go through a week long Third-Location Decompression Program designed to ease the stresses of adjusting to a normal home environment in Canada. The program provides education on what responses are normal, how long any symptoms should last and when and how to find help. CF personnel are strongly encouraged to seek care whenever and wherever they experience mental health problems.
All personnel returning from an international operation after 60 or more days undergo the Enhanced Post-Deployment Screening Process. This mental health review is undertaken three to six months after the return home. It is conducted in addition to the general medical screening and appropriate medical follow-up administered immediately following deployment. The purpose of this screen is to better identify those with deployment related problems, with a particular focus on mental health and psychosocial problems. To date, approximately 15,000 post-deployment screens have been conducted on military personnel returning from Afghanistan. While most military personnel have reported good mental health and experience no adverse effects, a small but important minority report symptoms of one or more of six common mental health problems. Symptoms of Posttraumatic Stress Disorder (PTSD) and/or depression are seen in about 5.5 percent 12 of our members. It is important to note that not all these people will go on to develop PTSD and/or depression.
CF personnel can seek treatment in many ways, depending on the degree of illness and the level of treatment required. The Member Assistance Program (MAP) of the CF, funded and managed by the CFHS, provides general access to confidential counselling from civilian practitioners. This is a short-term, non-therapeutic, problem-solving service only; accordingly, any member requiring long-term help or a more intensive specialized service is referred to an appropriate specialist.
The CF have established seven Operational Trauma and Stress Support Centres (OTSSC) across Canada in response to the increasing prevalence of PTSD and other OSIs. In addition to clinical treatment, these centres provide training programs on the avoidance, recognition, and reaction to stress injuries, as well as offering psychological, emotional, and spiritual support. To ensure continuity of OSI care, all operational CF bases 13 have mental health services that are available from their base medical clinic. As part of the Mental Health framework co-managed by CF and VAC, access to the OTSSCs is open to serving personnel and veterans alike.
To ensure consistency and continuity of mental health care, the CF, VAC, and the RCMP signed a partnership agreement with a view to setting up a network of VAC OSI clinics, which are complementary to the CF OTSSCs and guarantee the provision of standardized and continuous care to serving personnel and to those who are transitioning to the care of VAC. The OSI clinics have teams of mental health professionals that include psychiatrists, psychologists, nurses and clinical social workers who provide high quality standardized assessment, treatment, prevention and support services. VAC provides residential and out-patient care to serving CF personnel at the Veteran’s Hospital in Sainte-Anne-de-Bellevue, in addition to its OSI clinics in Vancouver, Edmonton, Calgary, Winnipeg, London, Ottawa, Québec City and Fredericton, which provide treatment to both serving personnel and veterans.
While clinical treatment is often a critical requirement in helping injured personnel recover from mental injury, an equally critical element is social support, which is provided by non-clinical programs and services. The CF, in partnership with VAC, developed an innovative peer-based intervention known as the Operational Stress Injury Social Support (OSISS) program. The OSISS has a national network of trained peer-support coordinators and family peer-support coordinators who have themselves experienced mental injuries, along with more than a dozen trained bereavement peer-support volunteers. These coordinators and volunteers provide empathic support, promote treatment-seeking behaviours, and more generally assist individuals who are experiencing coping and adjustment difficulties.
Awareness is key to both prevention and detection of mental health issues. The CF make great efforts to prepare and inoculate military personnel against operational stressors and to provide treatment and support when stress injuries and PTSD occur. Two key components of the awareness efforts of the CF are the Strengthening the Forces (STF) health promotion program and the Mental Health & Operational Stress Injury Joint Speakers Bureau (JSB). The STF program, managed in collaboration with mental health services, regularly offers skill-building workshops and supervisor training at all bases and wings to heighten the coping skills of members and strengthen their resistance to addictions through awareness and prevention, stress management, anger management, healthy relationships and suicide awareness.
The JSB offers a harmonized CF-wide training and education program to CF personnel that they can apply to various stages of their careers to increase their knowledge of mental health issues, improve their understanding of signs and symptoms, address the challenges of stigmatization, and promote early intervention. Education for family members of CF personnel is also a component of the program. These two programs aim to facilitate changes in attitude and behaviour, and organizational change through awareness. They also provide psychological fitness training to CF personnel at different stages of their careers, including in the course of initial recruit training. Training for all members allows them to take steps to preserve their personal wellbeing: leaders learn how to recognize and react to stress indicators in their personnel, all medical personnel receive clinical training on the recognition and treatment of symptoms, and in-depth specialized training is provided to mental health professionals.
Rehabilitation of a CF member must include the family. When a CF member is seriously ill or injured, the CF and VAC work together to provide support to the family. Although they are very resilient, many families require several forms of assistance in these difficult times, including child care, counselling and social support, and referral to local social service agencies. The Military Family Services Program (available through the MFRCs located on bases throughout the country), plays a pivotal role in providing these support services to families when a loved one has been injured or becomes ill.
The CF continue to support the families and communities of ill or injured personnel in the following ways: by ensuring services are in place to bolster family preparedness and resilience so that they can effectively manage the special demands associated with having an ill or injured family member; by doing what is necessary so that each casualty remains firmly connected to and supported by his or her family, particularly during lengthy periods of acute care and physical rehabilitation in distant specialized facilities; by providing in-home services and respite support to families who must provide additional and continuing care to a loved one throughout the recovery process; and by providing guidance for families who may be approached by the media at the very time that their privacy is of the utmost importance.
In response to evolving military family needs, the CF promulgated the CF Family Covenant in September of 2008. The Covenant establishes the social and moral foundations for all current and future CF policies, programs, and services as they pertain to military families. At about the same time, the CF launched initiatives focused on child care, mental health and social support, and access to medical care; initiatives also addressed spousal/ partner employment, spousal/partner education as well as reunions during and after deployments. Several of these initiatives give special consideration to the particular needs of families of an ill or injured member.
The CF have developed a management and transition framework that provides a consistent, integrated, and seamless process for CF personnel recovering from illness or injury, to help them progressively return to a normal work schedule and work load in the Regular Force or Primary Reserve, or to transition to COATS or the Canadian Rangers, or again, prepare for a civilian career and life.
Once an ill or injured member is medically stabilized and a permanent medical category is assigned, which may include MELs, an administrative review is conducted by the Director Military Career Administration (DMCA) staff. 14 The purpose of this review is to assess the effects of any MELs on future employability and suitability for continued service in accordance with the U of S policy and to provide the member with the opportunity to comment on the career recommendation prior to a final decision. 15
For severely injured or ill CF personnel who have been assigned permanent MELs, the CFHS will assess whether the individual has complex transition needs before DMCA conducts an administrative review. The criteria used to determine transition complexity include severity of the injury or illness, psychosocial factors, health care requirements and functional limitations resulting from the injury or illness.
Essentially, personnel will fit into one of three categories of suitability for continued service, each with a different career outcome.
The CF’s primary goal is to retain their highly skilled and experienced ill or injured CF personnel and ultimately return them to their previous employment. With that in mind, the CF have established a methodology to determine the acceptable medical boundaries of U of S.
The principle of U of S has been and will remain the cornerstone of all administrative reviews conducted to assess the effects of MELs on a member’s suitability for continued service.
Historically, the most difficult administrative reviews have concerned cases where a member suffers from a chronic condition that results in little disability, if any at all, but that can occasionally lead to medical crises in sudden and unpredictable ways. In these situations, the potential risk to the health and safety of the member should a medical crisis occur, and the effects of his or her potential performance failure on the operational mission or on the health and safety of others must be evaluated while taking into account the CF’s desire to retain personnel that are not only trained, but also productive.
The approach of the CF in applying U of S to such cases is to estimate as accurately as possible the medical risk involved. This is done by combining an estimate of the probability of an event occurring with the likely severity of the outcome and of the nature and urgency of medical care that would be required. The CFHS then communicates this medical risk to DMCA as a MEL detailing the percentage risk of an acute exacerbation occurring and its likely consequences. As part of the administrative review process, DMCA analyzes these risk-based MELs using the CF medical risk matrix 18 tool, which is a standardized grid that establishes the relationship between the probability of crises occurring and their severity. This tool assists DMCA in determining whether or not the overall risk is acceptable to the CF, and whether, therefore, a retention or release decision would be appropriate. 19
For example, some cases of kidney stones may have a 20 to 50 percent likelihood of recurrence over a 10-year period, a relatively high likelihood of occurrence. With a window of medical treatment of 72 hours and only moderate disability of the patient during an attack, the overall risk to the member and the likelihood of immediate performance failure are assessed as low enough for the CF to accept. Therefore, a member with such a condition would in all likelihood be retained without any employment limitations or career restrictions.
For those CF personnel who do not meet the requirements of U of S and will be medically released within either six months or three years, the CF will support a seamless transition to civilian life through SISIP and VAC programs.
All medically released CF personnel are entitled to a number of transition assistance services provided by the CF, SISIP and VAC. The vocational rehabilitation benefits of SISIP are available six months prior to release, and financial support is available at release. Most VAC benefits are only available after the effective date of release. However, VAC will become involved with the CF Case Manager while the member is still serving in order to ensure that VAC benefits and support services are in place when the client departs so that transition can be as seamless as possible. Several benefits and services are described below:
Ill and injured CF Regular and Primary Reserve Force personnel with MELs leading to medical release are eligible for a range of educational upgrading support services through the CF and the SISIP Vocational Rehabilitation Program (VRP) prior to departure. At the point of release, there is a coordinated transition from a CF education upgrade program to SISIP VRP, with an entitlement to financial and vocational support. This continues for 24 months after release. A CF member who meets the SISIP definition of totally disabled at 24 months post-release continues to receive long-term disability support to age 65. At release, that member may also communicate with VAC to request other support services in preparation for transition to civilian life.
VAC staff will provide a TI to all Regular Force personnel upon departure, all medically releasing Reserve Force personnel, and any CF member having completed an operational deployment during his or her career. The TI is an opportunity to provide CF personnel and their families with information on VAC benefits, programs, and services, to identify potential transition issues, and to facilitate access to VAC support.
Administered by JPSU, the TAP is an information portal on transition that includes job search tools, résumé writing resources and key transition links.
The COATS organization and the Canadian Rangers offer medically unfit CF personnel who no longer meet CF minimum operational standards, but satisfy the COATS/Rangers minimum medical requirements and enrolment criteria, an opportunity to continue to serve the CF in uniform, in a part-time or a full-time capacity.
This program permits eligible CF personnel, who have been notified of an impending medical release, to commence their participation in vocational rehabilitation while on duty for up to six months prior to departure, subject to the approval of their Commanding Officer.
SISIP LTD provides replacement-income protection to qualifying members who are medically released. 20 LTD benefits are equal to 75 percent of a member’s CF salary upon departure, minus income derived from all other sources, and they are payable for two years following release. Financial benefits may be extended if the qualifying member satisfies the SISIP definition of total disability. The SISIP VRP provides vocational rehabilitation training benefits to all SISIP LTD participants with up to $25,000 for tuition and related books. The member receives supporting allowances during the two years following release, and longer still, should he or she be determined to be totally disabled. Additionally, the SISIP VRP provides résumé preparation, job search training and targeted job leads to maximize the member’s opportunities for a return to the work force and effective re-establishment in the civilian world.
Recent amendments to the Public Service Employment Regulations allow for the priority appointment of certain medically released CF personnel to positions in any department of the Federal Public Service governed by the Public Service Employment Act. This priority can be activated any time within five years of the member’s release, and it gives the member two years of eligibility for priority appointment. Priority is also provided to surviving spouses or common-law partners of CF personnel whose death is attributable to service.
The New Veterans Charter is a comprehensive set of programs designed to provide CF personnel and their families with an opportunity for a successful transition to an independent and productive civilian life. It enables CF veterans to enjoy the best health possible, have the optimal chance for a quality job and, when necessary, receive earnings loss support to protect their standard of living. The Charter offers a single point of entry to a comprehensive suite of services and programs including one-on-one case management, a rehabilitation program, financial benefits, group health insurance, career transition services, the lump-sum Disability Award as well as other allowances and support to families. 21
Major Gagnon, a CF Regular Force member, learns while at home in Canada that he has been diagnosed with a treatable form of cancer. Married with two young children, he lives in a rural community just outside a major urban centre.
Major Gagnon is treated for his illness in a civilian health care facility; he has all the same been referred to the base surgeon (B Surg) and has been assigned a temporary medical category and a CF case manager. A Casualty Report has been issued to notify all potential players involved in his current and future support. An AO has also been assigned to him.
Major Gagnon manifested symptoms of depression, so he was referred to a mental health provider. A Health Services link nurse and the base chaplain have added their services to Major Gagnon’s provision of care. On the basis of the Major’s service record, his CO has ordered a summary investigation into the illness. Even though Major Gagnon’s illness may not appear at face value to be attributable to military service, a review of his personnel and medical files has led to the identification of potential occupational exposure to situations that could be linked to his condition.
The CO has asked the Director Military Careers (D Mil C) to post Major Gagnon to the JPSU for the remainder of his recovery and provide support and guidance during the rehabilitation and reintegration phases. The IPSC Director Military Family Support Liaison Officer (DMFS LO) has contacted Major Gagnon’s family to ensure that appropriate support is provided to his wife and children during this stressful period, particularly during the recovery stage when the future may appear uncertain. Owing to the distance that Major Gagnon must travel for his many hospital visits, the IPSC has requested funding assistance for medical and family travel.
Major Gagnon has completed his medical treatment and his program of care now shifts to the rehabilitation phase. A case conference has determined that he needs home modifications and some special services. The case conference, supported by the subsequent report of the occupational therapist, will also determine how these services are to be provided: either by the CFHS if they are covered by the Canadian Forces Spectrum of Care or by the IPSC if they are covered by a mobility aids Compensation and Benefits Instruction (CBI).
The Director of Medical Policy (D Med Pol) assigns permanent MELs to Major Gagnon as recommended by the attending medical officer. In consultation with the CF case manager, D Med Pol determines that he has complex transition needs. This information is sent to the DMCA, who initiates the administrative review process. Since Major Gagnon’s MELs breach U of S, DMCA determines that he will be medically released from the CF. An interdisciplinary team led by the IPSC services manager, and which includes representatives from SISIP and VAC, along with the CF case manager, develops an integrated transition plan with Major Gagnon, one that features individualized transition goals and projected timelines to achieve them.
These projected timelines are taken into consideration by DMCA in its determination of the medical release date. The IPSC staff and the CF case manager remain in touch with Major Gagnon throughout the transition period so as to ensure that he and his family are provided the support they need to successfully transition to civilian life.
Major Gagnon’s transition support plan includes vocational rehabilitation, which starts with the CF Education Reimbursement Program and is completed through the SISIP VRP.
As the medical release date approaches, the base release section and the base personnel selection officer (PSO) engage with Major Gagnon. The IPSC services section contacts Major Gagnon to ensure that he is aware of the TAP and the priority entitlement to employment in the federal public service. Additionally, SISIP FS will help him develop a résumé so that he can access both of these programs, and they will also provide targeted job leads.
Post release, Major Gagnon will be supported by VAC in accordance with the NVC.
Corporal Able, a member of the Primary Reserve, has sustained serious injuries in theatre. He is single, and his family lives three provinces away from his parent unit.
Following initial treatment at the Role 3 hospital in theatre, the unit releases a Casualty Report (CasRep) message to notify all players involved in the present and future support of Corporal Able, including medical services, the IPSC, and VAC. Initially, the CFHS take the lead in providing medical treatment and determining the appropriate time for other service providers to participate. The parent unit CO assigns an AO to Corporal Able. His parents are notified that he has been injured and is to be repatriated to Canada. The family is flown to the airport where they are joined by the CRT about two hours before Corporal Able’s arrival. The CRT plans and executes the aeromedical evacuation and the patient transfer over to the civilian medical facility in Ottawa, where Corporal Able will receive acute care.
The IPSC CF case manager team leader gives a status report to the service providers, informing them of when it will be appropriate for each to make their initial contacts. A CMT is convened to advise all service partners of Corporal Able’s progress and to plan for the continued provision of support services. The CMT will reconvene at various times during Corporal Able’s recovery and rehabilitation.
The IPSC asks the MFRC to address family concerns and provide support to the parents by offering them access to counselling and travel assistance.
Throughout recovery and rehabilitation, three IPSCs are supporting Corporal Able and his parents – the IPSC at Kingston, where Corporal Able’s unit is located, the IPSC in Edmonton, the city where his parents reside, and the one in Ottawa where he is being treated owing to the nature of his injuries.
Because of the treatment and rehabilitation required by Corporal Able, DCSM 2 extends his Class C contract after receiving a request to this effect from his parent unit.
When the CFHS define Corporal Able’s MELs, the CF case manager works with the AO to ensure that the information is relayed to Corporal Able’s CO. The B Surg and CO decide that Corporal Able should be posted to the IPSC Support Platoon in Ottawa, which provides the same administrative support and supervision as the member’s chain of command, including the staffing of further contract extensions. As a result, the parent unit disengages their AO.
The B Surg provides a prescription for RTW by completing a CF 2018. The IPSC RTW coordinator liaises with his civilian employer in the development of his RTW program.
The IPSC calls upon a peer support coordinator from the OSISS program to bring Corporal Able and his family in touch with their peer and family support networks, should they wish to do so.
The RTW Coordinator and the unit become more involved in Corporal Able’s progress during this stage. The IPSC Support Platoon updates the unit CO on Corporal Able’s progress so as to prepare for his return to duty in the Primary Reserve or for his civilian employment when he has fully recovered. In this example, Corporal Able recovers completely from his injury and returns to his position in the Primary Reserve.
The effective treatment and care of ill and injured CF personnel and the support provided to their families requires the mobilization of a complex network of expertise and capabilities, both military and civilian. It is clear that a comprehensive framework of care must have three major components: health services, casualty and family support, and career transition assistance and support. Each of these framework components has a distinct contribution to make. To the extent that we can integrate these three components and their many elements, we will achieve the desired level and standard of comprehensive care for our ill and injured members.
The CF are fully committed to providing care and support to the ill and injured and their families, as illustrated by the growth of health services, the creation of a new national JPSU/IPSC network and a host of supporting policies and programs. The JPSU in particular provides an integrated and individual-centric service delivery model, one that ensures the coordination and facilitation of standardized, high quality, consistent personal and administrative support during all the phases of recovery, rehabilitation, and reintegration. As a result, comprehensive care and support are available to all injured and ill CF personnel and veterans alike, and to their families and the families of the deceased.
1. As indicated in QR&O 2.034(c), the Cadet Organizations Administration and Training Service (COATS) consists of officers and non-commissioned members who, by the terms of their enrolment or transfer, have undertaken as their primary duty the supervision, administration and training of cadets or junior Canadian rangers.
2. Applies to Regular Force members regardless of whether or not the illness or injury is attributable to service and to Reserve Force personnel who are eligible for Reserve Force compensation or extension to Class C.
3. A military casualty is defined as a CF member who is seriously or very seriously ill or injured, is reported missing, has been killed, or has died.
4. Support functions offered by the JPSU include Return to Work coordination, casualty tracking, support outreach and administration as well as services provided by VAC, the Service Income Security Insurance Plan (SISIP), Personnel Support Programs (PSP), CFHS case management and Military Family Services.
5. The core team members are usually medical, logistical, pastoral and administrative support personnel, as well as representatives from the casualty’s home unit.
6. The Casualty Management Team is tailored to the specific requirements of each patient, but it generally includes the base surgeon, a primary care physician, a military liaison nurse, a CFHS nurse case manager (if the complexity of the case indicates a prolonged course of treatment and recovery), a physiotherapist, and a mental health specialist. Participation of the patient’s assisting officer, a chaplain, representatives from the Military Family Resource Centre and chain of command may also be deemed necessary. For more information, see Aide Memoire Casualty Reception and Management, a Canadian Forces Health Services Initiative, November 2006.
7. For more information, see Assisting Officer Guide, Casualty Support and Administration, Part I, Death, Part II, Injury/Illness.
8. The Role 1 Medical Treatment Facility (MTF) provides primary health care, specialized first aid, triage, resuscitation and stabilisation. Included within the Role 1 capabilities are: basic occupational and preventative medical advice to the chain of command, routine sick call, the management of minor sick and injured personnel for immediate return to duty, casualty collection from the point of wounding, and preparation of casualties for evacuation to the higher level MTF. The Role 2 MTF is a structure capable of receiving and carrying out triage of casualties, as well as performing resuscitation and treatment of shock at a higher level than Role 1. It will routinely carry out damage control surgery (DCS) and may include the setting up of a limited holding facility for the short-term holding of casualties until they can be returned to duty or evacuated. It may be enhanced to provide basic secondary care such as primary surgery, intensive care unit, and nursed beds. In addition to Role 1 capabilities, Role 2 includes several others: a resuscitation capability led by a specialist medical officer, along with the elements required to support it; postoperative care; a field laboratory capability; a basic imaging capability; a reception, regulation and evacuation of patients function, and a limited holding capacity. The Role 3 MTF includes, at a minimum, resuscitation, initial surgery, post-operative care, and short-term surgical and medical patient care. Diagnostic services, such as x-ray and laboratory as well as limited internal medicine and psychiatric services are also available. The facility can include: specialist surgery (neurosurgery, maxillofacial and burn surgery); advanced and specialist diagnostic capabilities to support clinical specialists (CT scan, arthroscopy, sophisticated lab tests); major medical, nursing specialties (internal medicine, neurology, intensive care, ophthalmology). Reception and storage of medical and dental materiel and blood in the area of operations (AO), and distribution to supported units is provided, as well as repair of medical and dental equipment within the AO.
9. OSI is a broadly descriptive category rather than a diagnostic term and, as such, it represents any persistent psychological difficulty suffered by a CF member following operational duties. The term OSI is used to describe a broad range of problems that can result in significant impairment of functioning. OSIs include diagnosed medical conditions such as depression, post-traumatic stress disorder (PTSD), and anxiety/panic attacks, as well as a range of less severe conditions.
10. For more information on the CF Rehabilitation Program see BG 11.011 – 27 September, 2011.
11. Mental health is defined as a subset of overall health that pertains to cognitive, emotional, organizational and spiritual matters, including psychiatric illness, intra-psychic disturbance, and problems in social and/or occupational functioning.
12. Report On The Findings Of The Enhanced Post-Deployment Screening Of Those Returning From Op Archer/Task Force Afghanistan as of January 2010.
13. Ottawa provides OTSSC follow-up in Petawawa, and Halifax provides on-site service to Gagetown.
14. DMCA is responsible for Regular Force personnel only. Reservist AR (MEL)s are conducted at the appropriate formation-level HQ.
15. The U of S policy of the CF and its associated minimum operational standards are described in DAOD 5023-0 and 5023-1. The principle of U of S or soldier first holds that CF personnel are liable to perform any lawful duty, that is to say, they must carry out general military duties and common defence and security duties, in addition to the specialized duties of their military occupation. In particular, the principle includes, but is not limited to, the requirement that all personnel of the Regular Force, Primary Reserve, and any other member serving with either the Regular Force or Primary Reserve be physically fit, operationally employable and deployable at all times. In a relatively small military force such as the CF, the maintenance of the operational capability and capacity of its personnel establishment is achieved by maximizing the trained effective strength (TES). This means that only those individuals who can contribute to operational capability can be retained in service. This condition of service does not mean that all seriously ill or injured personnel will automatically be released. Some will in fact recover sufficiently to be eligible for continued service.
16. A bona fide occupational requirement (BFOR) is generally defined as a condition or standard of employment (e.g., aptitude, personal characteristic, qualification, medical standard) that is reasonably and objectively necessary for the safe, efficient, and reliable performance of the job. Standards of employment perceived as inappropriate or arbitrary can lead to human rights complaints.
17. DAOD 5023-1 Minimum Operational Standards Related to Universality of Service.
18. For more information on the Medical Risk Matrix please see CANFORGEN 187/08 CMP 080/08 141648Z OCT 08 - Use of Medical Risk Matrix for AR/MELS.
19. DMCA is not the release authority for the medical release (3a/3b) of Reserve Force personnel. The Reserve unit produces the release notification, which it forwards to DCSM/JPSU for further action.
20. Coverage and benefits for Reservists vary according to their class of Reserve service.