Coordinated Case Management: Improving Outcomes For Transitioning Canadian Armed Forces Members



At present, close to 40% of Canadian veterans report difficulties transitioning from the Canadian Armed Forces (CAF) to civilian life (LASS, 2019). Additionally, the literature on military transitions underlines the need for early intervention as critical to a member’s long-term transition success, and can significantly alter a member’s long-term psychosocial outcomes.

This article will outline how two distinct federal government departments, the Department of National Defence (DND) and Veterans Affairs Canada (VAC), coordinate their respective case management (CM) services and apply CM best practices to support CAF members during the critical transition period. This article will also outline key components, tools and approaches that CAF and VAC coordinate to support positive outcomes for transitioning CAF members.

CM services are available to ill and injured serving CAF members who have protracted or severe health issues and are provided by nurses in a primary care setting. The transition process from military to civilian life can take years, and early engagement with a nurse case manager (NuCM) is crucial in preparing members and their families in their recovery and for all aspects of civilian life. Educating members on the factors that will impact their transition, such as health condition, lifestyle, community resources, healthcare and how to access each will ensure that they are well prepared to manage their health as they transition. Upon release from service, these members are then supported by VAC.

When a serving member is referred for CM, a comprehensive health assessment is completed utilizing the internationally recognized Intermed® tool. Using an interdisciplinary approach which incorporates all aspects of the biological, psychological and social domains, this tool assesses the member’s medication, functional, administrative, transition and healthcare system needs. The NuCM, in collaboration with the healthcare team, member and their family identifies key goals that will support them throughout the transition process. The goals are assessed and revised regularly, and the member is provided with an action plan which supports the identified goals. A key element of that transition process also includes timely and early engagement with a case manager from VAC. The CAF and VAC have collaboratively established a standardized approach to CM by sharing information that bridges gaps and supports identified needs and goals, particularly when it involves healthcare and aspects of well-being, to ensure a smooth transition and positive outcomes for members.

When a member’s release period and potential challenges have been determined, the CAF and VAC coordinate the release process to ensure there are no gaps in service at any point for the transitioning member. This integrated approach to CM typically takes place over a six-month period but may, on occasion, be much longer. The CAF and VAC case managers meet regularly and discuss the transitioning member’s goals and needs for re-establishment and directly share key information related to the transitioning member’s file, including the member’s Intermed® results and any other relevant reports or documentation that supports a veteran’s well-being. The CAF and VAC approach veteran well-being based on a framework that outlines seven domains: employment or other meaningful activity, finances, health, life skills and preparedness, social integration, housing and physical environment, and cultural and social environment. When a member is released and becomes a veteran, VAC will already have key insights into the veteran’s journey thus far, including the veteran’s physical, psychosocial, financial and physical environmental needs.

VAC utilizes distinct CM tools that directly support the veteran’s re-establishment. In 2019, VAC implemented a new, evidence-based CM tool that screens for the risks associated with post-service life, including frailty, suicide and homelessness. This screening tool determines the level of support required by veterans receiving services from VAC. VAC’s screening tool and CM assessment both utilize the Well-Being Framework. These two tools, in combination with a coordinated CM approach between both CAF and VAC, lead to improved outcomes for the veteran and their family.

Integrated Case Management services play a critical and strategic role in ensuring coordination of services which can help to mitigate more complex psychosocial issues for vulnerable veterans. The CM Models used by CAF and VAC follow the guiding principles of Case Management Society of America (CMSA) standards of practice, including comprehensive assessment and an interdisciplinary team approach in identifying needs, all of which work together to support members along the continuum of integrated case management. It is with this integrated, coordinated approach to supporting a member’s transition process that CAF and VAC truly hope to see improved outcomes as demonstrated in both the upcoming CAF CM research and Life After Service Study.


Canadian Forces Health Services Primary Care. Intermed®

Government of Canada (2019). Well Being Framework. My Transition Guide: Transitioning from Military to Civilian Life

Life After Service Study (LASS), 2019. Statistics Canada.

anna bottiglia

Anna Bottiglia, RN, BscN, is the national case management coordinator, Canadian Forces Health Services for the Canadian Armed Forces. She received her bachelor of sciences degree in nursing, Ottawa University, Ottawa, Canada. Anna started her career in 1982 as a pediatric nurse at the Children’s Hospital of Eastern Ontario in the pediatric intensive care unit and emergency department. She has worked in clinical research, home care and most recently the Public Health Agency of Canada in infection prevention and control. Over the past 15 years she has been participating in healthcare accreditation surveys with Accreditation Canada and working with the National Case Management team at the national level as the coordinator for the western clinics.

meghan macdonald

Meghan MacDonald, RSW, MSW, is acting national consultant, National Case Management Unit, Veterans Affairs Canada. She has a bachelor of arts degree from Mount Allison University, bachelor of social work degree (Dalhousie University), and a master of social work degree (Wilfrid Laurier University). Meghan’s love for case management began with her first position as an intensive case manager for high emergency department utilizers with severe mental health and addictions challenges in Toronto, Ontario. She is passionate about coordinating case management services to support complex clients, and is currently working as an acting national consultant with the National Case Management Unit at VAC.


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