The hallmark of Veterans Affairs' proud tradition of service to its Canadian veterans has been the capability to adapt and improve its services and programs to meet the ever changing needs of its veteran clients. VAC is currently facing some of the biggest challenges in its history. The aging demographic profile of the veteran population presents demands for increasing levels of service at a time when resource constraints are restricting efforts throughout the public sector. Over the last few years VAC has been preparing to meet these challenges, and all levels of the organization -- District, Regional and National offices -- have been developing new approaches to delivering services to clients.

The move toward a Client-Centred Service Approach in VAC was approved by the Branch Executive Committee in April 1995. This decision was supported by: (1) a long and proud tradition in VAC of changing or modifying service delivery in order to meet the changing needs of the client population; (2) evidence suggesting that challenges to self-sufficiency and independence increase considerably as the veteran and client population approached very old age (80+ years); and (3) recommendations for improvements to client service delivery from various sources including the Audit and Evaluation VIP Review (1995), the 1994 Task Force on the Roles of Health Professionals and the Auditor General's Report (1996).

While acknowledging that pockets of a Client-Centred Service Approach already existed within the department, the goal was to develop and implement a client-centred philosophy and practice throughout all areas of the organization. Through extensive consultation and work with groups from all levels of the organization, a national service delivery model was developed which defined VAC services and was the foundation for further development of nationally standardized client-centred services. The Brampton and Hamilton District Offices in 1996 conducted a joint project which looked at embracing the philosophy of client-centred service and identified organizational issues that needed to be addressed. The original Steering Committee, the CCS Model and Standards Committee, was mandated to further develop and implement the model's components: client contact, screening, assessment, action planning, implementation, monitoring and follow-up, and targeted assistance. Other areas of activity that required consideration included building standards, developing tools for support, system integration, team building, role definitions, training, and program streamlining.

Following two years of staff training, the Client-Centred Service Approach has now been implemented in all offices across the country. The computerized assessment and screening tools in the Client Service Delivery Network have also been released nationally, and follow-up work, including quality assurance, is now in the process of being developed.

All these activities are considered to be the basis of the Client-Centred Service Approach, which ensures that the client, regardless of point of contact, receives the right service, at the right time, by the right person in a consistent standardized fashion.

Through the philosophy of client-centred service, we strive to promote the following for our clients:

independence - being able to live in one's own home, in one's own community with as little help as possible. The requirements for independence are health, wealth and social integration.

autonomy - refers to the maintenance of identity and values and to having control over decisions concerning oneself. Autonomy can be maintained even when one becomes dependent on others because of frailty or disability.

wholeness - rather than dealing with a client as a candidate for one of a vast array of Departmental benefits and services, we take into account all of that person's needs. We try to integrate our service in the light of the total person. As well, we share all information about a client with them and encourage them to make their own decisions.

Efforts that began in 1993 have resulted in the development of a National Client-Centred Service Delivery Model, which was ratified by BEC in May, 1996. The Model enables staff to continue to provide quality service to clients based on an approach in which VAC's structure and activities are more responsive to client needs and the client's right to be more directly involved in decisions regarding the kinds of care and services they receive. The Model impacts all levels of the organization. Whether a client encounters an Area Counsellor, a Client Service Agent, a Regional Inquiry Unit staff member, Pension Officer, Head Office staff or any staff member throughout the organization, they are served using the client-centred approach. This approach puts the client at the centre of our business and ensures that we listen to and balance their needs with administrative requirements. It also provides for the review of current structures and program requirements to ensure staff are better able to offer quality services.

The Client-Centred Service Delivery Model outlines the steps staff follow in providing service to clients in a client-centred organization from a client's first point of contact through to Follow-up and Monitoring, as required.

Contact between an existing client, a potential client or a client's representative and a VAC employee/staff by phone, correspondence, in person or electronically.

A process of briefly gathering information, including the client's identity and VAC status, the nature of the request or presenting issue, and identifying actual or potential needs in order to determine the most appropriate direction(s) of client service. Screening occurs following client contact and is a prelude to other service activities, such as the provision of internal or external referral, provision of information, targeted assistance such as benefit and program delivery, or case management services such as holistic assessment.

Assessment generally follows the screening or targeted assistance processes. The client-centred approach to service delivery is based on a philosophy of caring that puts the client "at the centre" of all interaction directed at enhancing his or her quality of life. The client assessment process should "put into practice" all the values and principles that are embodied in the client-centred philosophy. Client-centred assessments should clearly articulate the client's values and preferences as well as his or her perception of past and present strengths, problems, needs and goals.

In collaboration with the client and appropriate significant others (spouse, caregivers, external agency workers and specialists) an Action Plan is developed to identify the priorities assigned to client needs, the long and short term client outcomes expected, and strategies to meet the desired outcomes. The Action Plan would also include roles, responsibilities and time frames. The client's view of "what needs to happen next" must become the dominant theme in all remaining collective decision-making and in all actions initiated to reach mutually agreed upon client goals and outcomes.

Refers to the implementation of the action plan with the involvement of the client.

Monitoring is an on-going, scheduled process which evaluates and documents client responses and outcomes to services, programs, and benefits. Monitoring strategies are driven by the dates established for review of long and short term goals in the Action Plan.

Follow-up refers to a one-time contact and action on a specific issue. Follow-up actions are part of and are included in the Monitoring service.

Is the provision of basic information about services and/or programs of the Department or about community supports.

Information occurs following screening and involves providing clients with required information such as names, addresses, phone numbers, etc. It implies that the client is able to initiate contacts and does not require VAC follow-up.

Aimed at addressing issues requiring specific staff interventions for a known or limited time period. The alternative next steps are resolution or a referral to an internal or external agency for assessment. Targeted Assistance usually involves benefit delivery. The referral process here provides the client the opportunity to choose whether to have an automatic referral follow-up by an appropriate VAC staff or they may choose to monitor referral action themselves and advise VAC staff if problems exist, unmet needs remain, or if actions taken were unacceptable.

Case management can be defined as a service model for working with clients who have problems that prevent them from being as independent as they would like to be. Case management enables clients to become more independent and autonomous by maximizing their choices and opportunities to access community resources. This usually results in a better quality of life for the client and his or her family.

The core case management functions are screening, assessment, care or action planning, monitoring, referral, advocacy, reassessment, follow-up and discharge.

Case Managers work with clients to identify various social, psychological, physical and environmental problems which prevent independent living and an optimal level of well-being. Once these problems have been identified through formalized assessment, the case manager works with the client and his or her family to create a care plan which lists the actions that must occur for the clients problems to be addressed.

When the client has a wide range of both short-term and long-term problems, the case manager should rely on the expertise of various members of a multi-disciplinary team. This will ensure that the action steps listed in the care plan can meet all of the client's current and future needs. Many of these needs can only be met through action steps which access a vast array of the best services and benefits available in the community. In order to tap into the full range of resources available in a community, the case manager must establish some linkages with a number of different individuals, groups and organizations.

As the case manager begins the process of building linkages, it may become necessary to perform two additional core functions of case management: ongoing advocacy and community development. Ongoing advocacy becomes necessary when a client's access to a service or benefit is prevented because of confusion over entitlement, eligibility or agency mandate and objectives. The case manager's role is to bring clarity to the situation so that clients can receive the services they need. Conversely, community development is the creation of services and benefits that do not currently exist. Community development involves establishing working relationships with individuals and groups who have the common goal of trying to help a client or client group with a particular problem such as transportation to medical appointments or establishing an emergency response team for elder/child/spousal abuse.

Being client-centred means that the client and his or her family are not passive, dependent receivers of goods and services. They are active partners who contribute to their own care and well-being. As active partners, they have roles and responsibilities and are accountable for making informed decisions and choices. The ability to make choices is the cornerstone of client-centred service. Admittedly, there are some clients who would prefer that VAC staff make the choices for them and we must recognize this choice as well.

A case manager's skills include, but are not limited to, positive relationship building, effective written/verbal communication, ability to effect change and perform critical analysis, plan and organize effectively and promote client/family autonomy. It is crucial for the case manager to have knowledge of services and benefits available.

Not all clients who require services and benefits from Veterans Affairs Canada require case management. If a benefit or service can be provided which meets the client's need without the requirement for ongoing follow-up and monitoring, then case management is not required.

There are three basic rules to who should and should not receive client-centred case management:

Rule #1 - Client-centred case management should not be offered to clients or caregivers who are fully capable of managing their own lives. Clients or caregivers who elect to be their own case manager need information, support and administrative assistance; however, they do not need us to manage their lives.

Rule #2 - Related to rule #1 - client-centred case management should be offered but not forced upon anyone who does not want it.

Rule #3 - Client-centred case management should be offered to clients who, for whatever reason, are not able to manage their own lives, either for a fixed or indeterminate period of time, and who both require and request assistance in order to make informed choices.

Veterans Affairs Canada advocates a client-centred approach to service delivery, which combines the efficiency, commitment, caring and compassion of a client-focussed approach with the added dimension of the client being a prominent partner in the service delivery process. This means that staff work with the client, not for the client in all aspects of service and care from accessing Departmental programs and services to linking up with community resources.

The broker type model has been at the heart of Veterans Affairs Canada's case management approach since the birth of the Veterans Independence Program. However breadth, not depth, was emphasized. Referral and branching (health professional) assessments have become crucial in order to analyse the needs of complex cases. As clients needs have intensified, the importance of the case manager's role has become critical.

In a client-centred approach, the Area Counsellor works with the client and the family to address a number of complex needs or problems. The Area Counsellor uses the case management model of service with the goal of enabling the client to "do the things he or she would like to do" with assistance as required. The Area Counsellor helps the client to accomplish this goal by using four case management functions: assessment, care planning and service coordination, case conferencing with teams, and ongoing advocacy. In order for the case management process to be client centred, the client and his or her family must have the opportunity to participate in each of these core functions as equal partners.

This section is designed to give the reader an overall sense of how the roles for VAC staff have evolved as a result of the implementing the Client-Centred Service Approach.

The following role descriptions include a brief history of how each role has changed and then outlines tasks each position will cover in their enhanced roles. Making the shift from a '‘program driven" organization that provides benefits and services, to one that actively promotes our client's well-being by looking at his or her over all needs requires a change in the roles of employees. It is important to note here that this shift does not take away from the superior service that VAC employees have given veterans and their families in the past, it acknowledges our client's changing needs and attempts to adapt with them.

Throughout the adjustment of staff roles, the client has remained a focal point, collaboratively at the centre of all activities. Just as VAC staff work with each client to have his or her needs met, VAC has worked and continues to work with each employee to adjust, develop, and aid him or her in this transition. This assistance has come in many forms, such as CCSA courses, in-services and forums on health and local services, and coaching or mentoring from leaders within VAC. This approach acknowledges the need for VAC to foster an environment of continuous learning for all its staff.

The roles discussed in this chapter include: Area Counsellors; Administrative Support Group; Chief of Client Services; Client Service Agent; Chief of Support Services or Administration and Finance Officer or Manager, Administrative Services; District Director; District Office Nurse; Senior District Medical Officers/District Medical Officers; Occupational Therapists; and Pension Officers.

The role of the Area Counsellor (AC) has been redefined under the Client-Centred Service Approach. The Area Counsellor role has evolved to include using a more flexible and responsive holistic assessment approach to client needs. This enhanced assessment practice is required for the creation and management of a comprehensive case plan with the client, involving all client needs, not just those related to a program benefit. These changes represent a major shift from the traditional role of the Area Counsellor where the focus was to assess and provide clients with Departmental services and benefits. Counsellors must now focus more on the "at risk" client, exploring all aspects of their well being. Area Counsellors are expected to have a working knowledge of issues relating to the provision of case management services.

The Area Counsellor's work is now focussed on the results of interventions and their impact on the client's well being. An Area Counsellor is responsible for monitoring the interventions to ensure they achieve the client's and VAC's goals.

As a member of the client service team, the AC will:

• case manage by using a collaborative, multi-disciplinary approach on behalf of the client targeted to meet all his or her health and psycho-social needs.

• engage case management skills while determining the length of assessment and mode of assessment delivery required to meet the client's needs.

• conduct a comprehensive client assessment that includes collection of information relating to the client's level of physical and mental functioning, and financial and social circumstances to determine both immediate and long-term needs.

• conduct assessments of caregivers of veterans, in conjunction with assessments of the client, to ensure caregiver needs are also met.

• respect client self-determination and help clients make informed decisions and prioritize issues. This includes identifying obstacles to problem resolution, as well as interventions that may be appropriate but not agreed upon by the client.

• use a collaborative approach to formulate mutually agreed upon goals and interventions in a care plan with the client. The AC will do this care planning activity in consultation with other members of the client service team as required.

• provide ongoing monitoring, counselling, referral and advocacy, as well as establishing linkages for therapeutic interventions with the client's permission.

• analyse planned interventions to ensure the needs of clients are being met. If the planned interventions are unsatisfactory or unexpected client outcomes are evident, the Area Counsellor will revise the action plan ensuring that the services, programs, and benefits in place are appropriate and reflect the client's needs and eligibility.

• address any identified unmet needs through existing internal or external resources, or through the development and expansion of new or existing services.

• continue to advocate on the client's behalf and play a crucial role in community development resulting in or from partnerships with internal health professionals and local agencies and providers.

• continue to assess and adjudicate on Veterans Independence Program benefits and Special awards and make recommendations for treatment benefits etc.

• continue to have responsibility for cost effective program delivery which includes authorizations and recommendation of VAC benefits and services.

• conduct a client screening with the client's consent. Through the screening process, gather information to confirm the client's identifying information. Identify requests and client-based changes and problems to:

  1. clarify the client's reason for contact
  2. identify and clarify changes in circumstances
  3. identify potential problems and changes
   

• document actions taken including:

  1. any problem/change identified.
  2. information concerning actions taken, either external referral, targeted assistance (program/benefit application/delivery), and/or referral for assessment.
  3. information regarding actions not mutually agreed upon with the client.
     

• provide a basic service to clients and their families who are not currently in receipt of Departmental benefits focussing on a needs-based approach.

• participate in activities to promote awareness of the VAC mandate including CCSA, commemoration and programs, services and benefits.

• identify gaps in services for veterans and use community development practices to ensure services are available.

• engage with clients in supportive counselling to link them to appropriate health professionals. It is acknowledged that supportive counselling is a work activity in and of itself even when the provision of a program or benefit does not occur.

The role of the Administrative Support Group (ASG) will change from working on functions and tasks often seen as separate from the clients to working directly with clients and client service teams.

This group consists of the Receptionist, Pension Assistant, System Operational Support, Paramedical Assistant, and the Cashier. The ASG will become more generalists in nature combining more than one function so that more staff can be devoted to direct client service, while recognizing the need for specialization in pension support and systems administration. The work of the ASG is quite diverse and will become more so.

As a member of the client service team the ASG will:

• support the operation of the office for mail, files, supplies, security, cashier and system support.
• support the Pension Officer, including direct client service, conducting initial screenings for the Pension Officer, updating clients on their applications, following up with clients to request additional information.
• support the District Medical Officer including direct client service such as booking medical examinations for clients and assisting clients with medical travel claims.
• provide direct contact at reception of clients who walk in or telephone the published number.
• provide direct support to client service teams (Area Counsellor, Client Service Agent, and District Office Nurse) on program/administration.
• provide basic Departmental or other external agency information, e.g. include names, addresses, phone numbers and other similar requests.
• play a crucial role as the first contact point to direct clients and agencies to the appropriate individuals responsible for screening.
• direct clients/potential clients to the appropriate program/benefit related-staff, by-passing screening in the following situations:
  1. Follow-up contact related to an ongoing action/matter.
  2. Return of a department generated contact (i.e. telephone call).
  3. Contact by appointment.
  4. Client request of by-pass.

The Chief of Client Services (CCS) role is pivotal in acting as a change agent or mentor for the client-centred shift. The CCS does not have responsibility for performing individual components of the Client-Centred Service Delivery Model, but the role of mentoring requires the CCS to move from being managers of benefit administration to facilitators of interaction with all members of the client service team. The CCS must continually reinforce the need and reasons for change and to provide continuous support and encouragement to individuals and teams. Ensuring consistent application of process and adherence to standards is also a key role to be achieved through quality assurance processes.

As a member of the client service team, the CCS will:

• Develop the capacity of individual team members by:

  1. ensuring the shift of the low risk cases to the Client Service Agent.
  2. ensuring that the screening process is functioning well.
  3. ensuring that Area Counsellors understand and are fulfilling their new roles in case management, case coordination and care planning.
  4. ensuring District Office Nurses (DONs) understand and are fulfilling their new roles in consultation, training, community development, institutional care review and quality assurance of other nursing assessments.

• Develop the capacity of the client service team by:

  1. promoting more open communication and lateral decision-making among all team members
  2. promoting consensus in problem solving.
  3. promoting and supporting the interconnectedness of each role.
  4. reinforcing team accountability to team members and to the client, and as a functional unit.
  5. encouraging staff to assist each other through case consultation and peer review.
  6. introducing guidelines, protocols and training sessions that guide the team toward becoming a client-centred unit.
  7. providing direction on the expectations and goals of the team in order to facilitate the role change process.

• Carry out a planning role as part of the District Office Management Team by:

  1. ensuring that efficient processes are in place to meet the needs of clients
  2. making recommendations for ensuring DO resource levels meet clients' needs.
  3. supporting team concerns, successes and challenges to management teams.

• Carry out a coaching and training role by:

  1. ensuring ongoing training for all members of the team.
  2. ensuring support and value in diversity and shared decision making.
  3. creating an environment where people can trust and empower others to take risks.
  4. ensuring ongoing communications processes involve staff, clients, service providers and partners.
  5. providing direction on expectations and goals to individual team members.
  6. identifying and dealing with team gaps in performance outcomes.

• Be responsible for the overall integrity of case management in a client-centred approach by:

  1. being involved in an intensive quality assurance process.
  2. accompanying staff on home visits.
  3. identifying trends or issues that may require policy change and liaising with the Regional Directors Client Services on these issues.

• Be responsible to interpret policy and ensure its consistent application. The Chief Client Services will also recommend changes in VAC policy and regulations to meet the changing needs of our clients.

• Lead or be involved in the evaluation of clients' satisfaction with services, programs and benefits, and the delivery processes related to same. Information will be obtained from the client and caregivers, formal and informal (i.e. nurse, the spouse etc.)

• Identify gaps in service delivery and work with the District Director and others to develop strategies and approaches to address these gaps (e.g. recommend changes in policy/regulations or promote the development of new community programs and services).

• Promote and represent VAC with veterans organizations and other service associations.

• Support counselling staff carrying case loads but not, as a matter of course, carry out extensive administrative duties.

The role of the Client Service Agent (CSA) has been redefined to provide the critical "front end" screening function for clients requesting services from Veterans Affairs Canada through a phone, mail and walk-in. The role of the Client Service Agent will evolve into providing more coordination, referral, targeted assistance and information to those clients defined as low risk.

As a member of the client service team, the Client Service Agent will:

• assume responsibility for the administrative program requirements related to targeted assistance e.g. Veterans Independence Program, Treatment Automated Processing System (TAPS) and Special Awards.

• initiate or direct the client to application for programs or benefits, when requested or required by the client.

• provide assistance to clients in accessing the Department's programs and services or in providing information regarding resources offered by federal, provincial or community-based agencies.

• provide basic information about services and/or programs of the Department or about community supports when requested by client.

• assume more responsibilities related to client visits to the office through identification of clients' problems/changes via the screening process and referral to the Area Counsellor/District Office Nurse as needed. They can also be involved in referral and coordination on behalf of clients.

• gather and confirm clients' identifying information through the screening process, with the client's consent. Client Service Agents will also identify requests and client-based changes and problems while documenting the following:

  1. any problem/change identified.
  2. information concerning actions taken, either external referral, targeted assistance (program/benefit application/delivery), and/or referral for assessment.

• information regarding actions not mutually agreed upon with the client.

• screen clients at program/benefit related contact and review points i.e. VIP Low Risk Annual Follow-Up.

The Chief of Support Services (CSS) is integral to the smooth functioning of a client-centred office. The CSS position has shifted from a strictly administrative one to a supportive managing role. This shift encompasses a greater responsibility for the CSS to foster a client-centred office atmosphere. This means providing leadership and embodying "client-centred" practices in the workings of the district office's day-to- day functions.

As a member of the client service team, the CSS will:

• monitor, control, and evaluate Area Office/District Office financial/administrative activities including commitments, expenditures, accounts receivable/payable and banking; forecasting resource requirements and preparing financial submissions and budgets; advising on the financial implications of proposed activities; compiling and analysing statistical reports from multiple sites and preparing performance and other reports.

• coordinate the operation, functioning and follow-up of the Area/District Office micro/mainframe computer systems.

• manage, coordinate and evaluate the delivery of general administrative services/work flow in a client-centred manner. This includes cashier and reception services, records management, mail room services, accommodations, telecommunications, security, occupational health and safety, and material management.

• participate as a member of the Area/District Office Management Team in developing operational goals, formulating financial and human resource plans, and in planning, implementing and evaluating office space utilizations, new initiatives necessitated by corporate restructuring on the changing needs of the client group.

• coordinate and controls the contracting activities to ensure they are managed and maintained in accordance with the Treasury Board Policy and the principles of client-centred service.

• manage the Area/District Office cemetery restoration program and the Special Equipment Inventory Control System.

• coordinate the flow of financial information and monthly advance payments between Regional Office Finance and the contract institution; assisting with the annual audits of these institutions; and assisting with collection of outstanding board and lodging accounts.

• plan, coordinate and implement partnerships and shared services with other Federal, Provincial and Municipal public service agencies in areas such as administrative support, staffing, training, accommodation, freight and telecommunications.

• supervise and provide leadership for administrative staff located at multiple work sites.

The role of the District Director (DD) has expanded under the client-centred approach to support the district office at both the operational and corporate levels. They must demonstrate their ongoing commitment to the Client-Centred Service Approach to ensure consistency of service delivery and dedication to the National Client Services Standards. At the operational level, the District Director is the key manager, and is ultimately responsible for the successful implementation of the Client-Centred Service Approach into the district's day-to-day operations. At the corporate level, the District Director is the key manager to communicate any changes or concerns to other parts of the organization that may result from or impede the successful implementation of the Client-Centred Service Approach.

As a member of the client service team, the District Director will:

• demonstrate, communicate and reinforce the importance of the shift from a program-driven to a Client-Centred Service Approach.

• demonstrate commitment to staff by championing concerns raised.

• lead, participate in and facilitate the change process.

• provide coaching, consultation and mentoring for the Chiefs of Client Services and Support Services.

• monitor the progress of the change process in terms of the shift to the CCSA in their area of responsibility.

• ensure performance measures are in place to track the success of the CCSA.

• continue to be involved in community, regional and national networking.

• assume more responsibility to market the CCSA to veterans organizations and other community groups.

• be responsible for negotiating service arrangements for veterans at an agency-to-agency level in the community to ensure access to high quality services for veterans in the community.

• ensure the effective and timely dissemination of information to staff.

Implementation of the Client-Centred Service Approach to the delivery of programs and services has resulted in an expanded role for the District Office nurse. The nursing role involves the performance of diverse functions. While maintaining their primary responsibilities relating to conducting and reviewing nursing assessments on the client with complex needs, pre-authorization of benefits such as oxygen or nursing services, participation as a member of the Health Care Team and doing follow-up on issues relating to institutional care, VAC DONs are playing a larger role as a member of the client service team. The nurse will liaise with health professionals in the community and will provide increased consultation and information services to VAC staff to support the management of complex and high risk cases. Key functions relating to the nursing role are as follows:

• analyzes specialized and complex data provided by respiratory therapists and physicians for the purposes of approving or declining oxygen benefits.

• analyzes and clarifies client assessment data provided by Home Nursing agencies in order to pre-authorize the funding of professional nursing care in the client's home.

• provides ongoing consultation and information services to VAC staff regarding health issues relating to veterans/caregivers and Regular Force.

• plans and delivers education and training relating to health issues to VAC and contract staff.

• plans and facilitates health promotion and caregiver education activities with VAC staff, veterans, their families and/or caregivers.

• conducts comprehensive nursing assessments on veteran clients and Regular Force to identify client needs, to promote and maintain health, independence, and quality of life and for case planning purposes.

• participates in the development of palliative care plans and conducts comprehensive nursing assessments and regular follow-up of clients in the terminal phase of illness.

• plans, implements and evaluates case management plans in partnership with the veteran and Regular Force client and the multi-disciplinary team.

• conducts quality assurance reviews of nursing assessments conducted by contract nurses.

• analyzes and reviews, using the nursing process (assess, plan, implement, evaluate), information contained in health assessments conducted by nurses or allied health professionals in order to identify client needs; contribute to case plans and evaluate health outcomes for client health and independence.

• designates the federal type of care based on nursing assessment data to comply with Departmental policy and regulations to provide health benefits and services to clients.

• consults, coordinates and collaborates with provincial and community organizations and agencies in order to achieve and maintain the optimal health and well-being of veteran clients.

• conducts quality assurance activities with other members of the multi-disciplinary team on case plans.

• plans and facilitates health promotion and caregiver education activities with VAC staff, veterans, their families and/or caregivers.

• participates with community agencies in developing care plans for clients, and planning or delivering support sessions to therapy groups and caregivers.

• identifies gaps in health care services for veterans in their respective communities and uses community development practices to ensure that the necessary services are available.

• provides functional direction to contract nurses.

• coordinates access to and participates on Provincial/Regional and institutional admission committees of facilities providing Departmental, contract and community beds.

• monitors quality of care, initiates and coordinates processes relating to the resolution of complaints by Veteran clients in Departmental, contract and community beds.

• provides leadership and nursing expertise on client-centred service delivery to the multi-disciplinary District Health Care Team (DHCT) and VAC staff.

• authorizes and/or recommends Departmental health care benefits and services.

• collaborates with VAC Departmental personnel and participates in activities to promote awareness of VAC's mandate.

• conducts a client screening with client's consent. During the screening process the District Office Nurse will gather information to confirm the client's identifying information. Identifies requests and client-based changes and problems to:

  1. clarify the client's reason for contact.
  2. identify and clarify changes in circumstances
  3. identify potential problems and changes

• 1. any problem/change identified.
  2. Information concerning actions taken, either external referral, targeted
  3. assistance (program/benefit application/delivery), and/or referral for assessment.
  4. Information regarding actions not mutually agreed upon with the client.

The role of the Senior District Medical Officer/ District Medical Officer (SDMO /DMO) has expanded under the Client-Centred Service Approach. Their current responsibilities involve providing assessments targeted at specific programs and\or benefits (e.g., Pension exams), continuing to organize and direct the medical activities of the district office and to participate as a member of the Health Care Team. They will now take on a larger role as part of the client service team and provide a consultation service to the team to help meet the unmet needs of the "at risk" client.

As part of the client service team the SDMO/DMO will:

• identify clients who may be experiencing difficulties managing independently in the community and refer to the appropriate team member for follow-up.

• provide advice, support and assessment (based on medical cues for referrals) to the client service team and other VAC staff as required.

• arrange and/or advocate with other medical professionals in the community, on an as-needed basis, to clarify or obtain needed medical information or services for clients, including consultations and hospitalizations.

• establish and maintain effective working relationships with external health service providers, including licenced medical practitioners, other related health professionals, community care agencies and lay organizations as required.

• play a key role in the collaborative approach to health promotion.

• participate in community educational programs, seminars, etc. to promote healthy living in seniors, especially veterans' population.

• organize, direct and manage Contract Medical Officers such as AMEs.

• conduct a client screening with client's consent. During the screening process the SDMO/ DMO will gather information to confirm the client's identifying information. Identify requests and client-based changes and problems to:

  1. clarify the client's reason for contact.
  2. identify and clarify changes in circumstances.
  3. identify potential problems and changes.

• document actions taken including:

  1. any problem/change identified.
  2. information concerning actions taken, either external referral, targeted assistance (program/benefit application/delivery), and/or referral for assessment.
  3. information regarding actions not mutually agreed upon with the client.

The Occupational Therapist (OT) plays a key role as a member of the District Office Health Care Team. They bring a specific set of diagnostic and rehabilitative skills to multi-disciplinary client care planning. The OT role has evolved into one of consultation to other members of the health care team.

As part of the client service team the OT will:

• assess clients or review the assessments of other OTs when referred by Area Counsellor or District Office Nurse for special equipment, mobility issues, home modifications or other treatment benefits.

• provide teaching and coaching to clients regarding equipment use.

• provide in-service education and training to district and regional staff.

• provide consultation with District Office Nurse when client has difficulty in performing Activities of Daily Living/Instrumental Activities of Daily Living especially problems related to feeding such as: positioning, swallowing, dysphagia, and mobility.

• consult with Area Counsellor when limitations due to physical and /or mental impairment compromise the clients safety vis a vis his/her physical environment.

• consult with Area Counsellor when special equipment and/or home modifications are required to client's residence.

• be active members of the client service and health care teams (when on staff versus on contract with VAC).

• conduct a client screening with client's consent. During the screening process the Occupational Therapist will gather information to confirm the client's identifying information. Identify requests and client-based changes and problems to:

  1. clarify the client's reason for contact.
  2. identify and clarify changes in circumstances.
  3. identify potential problems and changes.

• document actions taken including:

  1. any problem/change identified.
  2. information concerning actions taken, either external referral, targeted assistance (program/benefit application/delivery), and/or referral for assessment.
  3. information regarding actions not mutually agreed upon with the client.

The role of the Pension Officer (PO) has expanded under the Client-Centred Service Approach. While their primary focus continues to be assisting veterans with needs related to targeted assistance (disability pensions), the Pension Officers and Pension Assistants become an integral part of the client service team providing expert advice on pension matters and referring clients requiring additional support from other members of the team.

As a member of the client service team, the Pension Officers will:

• assume more responsibilities related to client contacts (visits to the office, satellites or telephone) through identification of clients' potential needs via the screening process and referrals to the client service team for coordination. This may include assessment of health related matters and Special Awards and Ancillary Benefits on a case by case basis when required.

• continue to be involved in making referrals to SDMO/DMO for targeted assistance (additional pension).

• provide expert advice on pension matters as needed at Health Care Team meetings.

• conduct a client screen with the client's consent. Through the screening process, gather information to confirm the client's identifying information. Identify requests and client- based changes and problems to:

  1. clarify the client's reason for contact.
  2. identify and clarify changes in circumstances.
  3. identify potential problems and changes.

• document actions taken including:

  1. any problem/change identified.
  2. information concerning actions taken, either external referral, targeted assistance (program/benefit application/delivery), and/or referral for assessment.
  3. information regarding actions not mutually agreed upon with the client.

Client-Centred Service Approach Standards»»