Shaken world

A 30-year-old female Canadian Forces (CF) Veteran^* presents to a family physician for a first visit. She complains of back and knee pain and feelings of depression. She has a grade-12 education. She served as an infanteer for 12 years, including a 6-month tour in Afghanistan. She voluntarily left the CF 3 years earlier at the corporal rank, after developing back and bilateral knee pain. She has been struggling since moving her family “back home” after leaving the CF. She is estranged from her family of origin, misses her “military family,” and feels socially isolated.

She has not had a regular family physician since leaving the CF, obtaining prescriptions through walk-in clinics and hospital emergency departments. Owing to pain, she is unable to work in the physically demanding occupations for which she was trained. Her husband believes she should contribute to the family income and says she is irritable and sleeping poorly. She is taking opioid analgesics and a muscle relaxant. With the patient’s consent, the physician obtains her medical service records from the CF. After assessing her symptoms with history, physical examination, and appropriate investigations, he diagnoses chronic mechanical low back pain, bilateral patellofemoral syndrome, and an unclear mental health condition. He arranges referral to a provincially funded pain clinic with a 1-year waiting list and books follow-up visits to review her pain medications. After hearing about the New Veterans Charter programs, he refers her to a Veterans Affairs Canada (VAC) district office to see if she is eligible for the VAC Rehabilitation Program and mental health assessment, and sends a letter describing her history and the reason for referral.

Transition from the military to the civilian world is a special turning point in the life course of military Veterans and their families.¹ For most, transition is a smooth experience, followed by easy adaptation to new lives in new homes. For some, transition is difficult, especially when physical or mental health problems create barriers to successful reestablishment in civilian life.^2,3 There is a small but growing amount of literature for Canadian physicians caring for Veterans.^4-6 This article describes family physicians’ roles in VAC’s Rehabilitation Program, which is designed to improve reestablishment outcomes for Veterans and their families.

From military to civilian life

Military service is very different from civilian life. Veterans speak of the camaraderie of the “military family,” in which needs are addressed in a highly structured culture. Canadian Forces members have ready access to health care and know their rank in the organization. They often bond closely with unit members. Family relationships can be strained by moving to new postings every few years and long family separations during training and deployment. Park recently described the demographics of the modern CF.⁷

There are no commonly accepted definitions for the start and end of transition to civilian life, which happens at all ages after short and long periods of service. It might start early, as some recruits plan ahead. For most, transition starts when members begin to think about leaving the service or realize involuntary release is pending. Administratively, transition starts when members are told they are being medically released or formally signal their intention to leave voluntarily.

Transition to civilian life can bring unexpected feelings and problems: loss of the military family and the member’s identity; disorientation in an unfamiliar civilian world; a period of readjusting to being with family full-time; and difficulty finding a family physician in a new community. For those who welcome release, transition might end days after their last day in uniform. Others gradually adapt over months or years to civilian jobs, communities, and family life. Successful transition can be very difficult for those who continue to miss military life or who struggle to adjust to the civilian world when they have physical or mental health barriers.

Medical release

When CF members are medically released from service as a result of chronic physical or mental medical conditions that prevent them from remaining operational, their conditions are usually well described and being treated. Medical release accounts for about one-fifth of the roughly 4000 members leaving the CF annually. Transition of members released for medical reasons is usually planned and coordinated before release by the case managers in VAC and the Department of National Defence and the CF.

Voluntary release

Voluntary release is much more common than medical release. Canadian Forces members can leave voluntarily with 30 days’ notice, which leaves little time for transition counseling. Some members who have left the CF voluntarily did not fully disclose their health issues before leaving. Some members believe their health problems will disappear after they leave military service, only to find the problems become substantial barriers in civilian life. Although members receive information about VAC services and are encouraged to attend transition interviews before release, they might give priority to other details.

Role of the family physician

In spite of the best joint efforts by the Department of National Defence, the CF, and VAC to engage members in transition health planning before release, some members might still present to civilian family physicians with health problems that prevent successful reestablishment in civilian life. In such cases, the family physician investigates, diagnoses, and treats the symptoms as usual and organizes referrals as required. Family physicians can obtain medical service records and collaborate with the VAC district office interdisciplinary client service team to ensure continuity of care for Veterans and their families during transition.

While taking the history from patient and family, the physician makes note of their perceptions of how the symptoms relate to military service. As part of the treatment plan, the physician can encourage the Veteran to contact VAC. With the Veteran’s permission, the physician can send a referral letter to the Senior District Medical Officer at the local VAC district office outlining the problems, social and medical history, diagnoses, treatment plans, and reasons for referral.

Rehabilitation at Veterans Affairs Canada

A comprehensive, multidisciplinary approach to long-term disability care that includes medical, psychosocial and vocational rehabilitation is important.^1,8,9 In 2006, the Canadian government introduced sweeping changes for CF members, CF Veterans, and their families under the New Veterans Charter.¹⁰ Depending on eligibility, services might include case management, rehabilitation, financial benefits, group health insurance, job-placement assistance, support for families, and various health benefits. The VAC Rehabilitation Program connects eligible Veterans and their families with medical, psychosocial, and vocational rehabilitation professionals to manage health problems interfering with transition to civilian life.¹¹

District office area counselors (AC) are case managers. They meet with clients in their homes for comprehensive assessments covering health status and social situation, identifying key problems and needs. The AC explains VAC services and encourages the client to apply for those relevant to the client’s needs, such as the Rehabilitation Program. The AC determines eligibility for the New Veterans Charter Rehabilitation Program in consultation with the VAC district office interdisciplinary client service team, which includes a team manager, the AC, a physician, a nurse, and an occupational therapist. Clients are eligible if they were released for medical reasons or if they have health problems that can be attributed to military service that create barriers to adjusting to civilian life. Veterans Affairs Canada encourages family physician involvement in all stages of rehabilitation.

With the client’s permission, the family physician can participate in various ways with the VAC district office interdisciplinary client service team to develop a rehabilitation case plan to meet the client’s needs. The family physician can provide an opinion on the nature of the health problems, functional effects, treatment, and prognosis. As the primary VAC case manager, the AC discusses the plan with the client, implements the plan, monitors the client’s progress, and updates the team, which could include the family physician.

The patient in our fictitious case would have received expedited referrals to providers contracted by VAC, including but not limited to the following:

• a psychologist or psychiatrist for mental health assessment, diagnosis, and treatment;

• a chronic pain management program;

• a social worker for family and marital counseling; and

• a vocational rehabilitation professional for employability assessment.

If the vocational rehabilitation professional finds the client is not currently employable, temporary or long-term financial support is available. The AC consults the interdisciplinary team to consider whether or not the client is totally and permanently incapacitated for gainful employment; clients with this status are eligible for financial benefits until age 65, are reassessed annually, and are provided with access to rehabilitation services for spouses or partners.

The AC and family physician monitor the client’s progress through the rehabilitation case plan, discussing issues as needed. Family physicians can participate in case conferences with the client’s interdisciplinary client service team.

Veterans Affairs Canada welcomes family physician participation when assisting eligible CF Veterans who require support transitioning to civilian life after leaving the military. Through shared case management by her family physician and her AC, the Veteran in our fictitious case worked through her rehabilitation plan to achieve control of her pain, obtain satisfactory employment, and enjoy a healthy civilian family life.

Resources

Resources for physicians

• Department of Defence and Canadian Forces website: www.forces.gc.ca (search using the word transition for information on transition services available to still-serving members)

• Veterans Affairs Canada (VAC) website: www.vac-acc.gc.ca (search using the words transition, New Veterans Charter, or mental health for information on services available to Veterans)

• VAC client service team in a district office: telephone 866 522–2122 (If the Veteran is a client, it helps to have his or her VAC client number handy)

Resources for Canadian Forces members and Veterans

• Department of Defence and Canadian Forces website: www.forces.gc.ca (search using the word transition for information on transition services available to still-serving members)

• VAC website: www.vac-acc.gc.ca (search using the words transition, New Veterans Charter, or mental health for information on services available to Veterans)

• Assistance accessing VAC services: telephone 866 522–2122 (English) 866 522–2022 (French)

• Veterans Assistance Line (up to 8 free counseling sessions): telephone 800 268–7708

BOTTOM LINE

• Transition to civilian life is successful for most military members but can be difficult for some with physical or mental disabilities.

• The military context of health issues is important in assessing and caring for military Veterans.

• Comprehensive medical, psychosocial, and vocational rehabilitation assists in helping disabled Veterans to transition successfully.

• Veterans Affairs Canada offers a range of expedited services to assist Canadian Forces Veterans and their families whose health issues create barriers to successful reestablishment in civilian life.

POINTS SAILANTS

• La plupart des membres des FC réussissent leur transition à la vie civile; cette transition peut toutefois se révéler difficile pour ceux qui souffrent d’une incapacité physique ou mentale.

• Il est important de tenir compte du contexte militaire lié aux problèmes de santé dans l’évaluation et le traitement des anciens combattants.

• Une réadaptation médicale, psychosociale et professionnelle complète aide les anciens combattants atteints d’une déficience à effectuer une transition réussie.

• Anciens Combattants Canada offre une gamme de services accélérés afin de venir en aide aux anciens combattants des Forces canadiennes et à leurs familles dont les problèmes de santé entravent la réussite de leur réinsertion à la vie civile.