Canadian Armed Forces Members’ Perspectives on Health Service Transition Prior to Military Release

Abstract

In Canada, military-to-civilian transition (MCT) involves transitioning from military to civilian primary care. This is an important but underexplored aspect of MCT. We investigated releasing military members’ perspectives on the transition from military to civilian primary care by analysing previously collected interview data from 69 Canadian military members. We found that participants were apprehensive about accessing primary care after release, felt more support from the military was needed, and made recommendations for improving support. Our findings help explain the high proportions of difficult adjustment to MCT among veterans and highlight the need for more robust support for releasing military members.

Key Words: transition to civilian life, Canadian Armed Forces, veterans, primary care, qualitative methods.

Introduction

Approximately 5000 Canadian Armed Forces (CAF) Regular Force members leave service annually.¹ Military-to-civilian transition (MCT), which begins well before the official release date, marks a major turning point in the life of CAF members and has implications for wellbeing.² While most veterans report an easy adjustment to civilian life, the proportion of veterans reporting a difficult transition is growing.³ An inherent aspect of MCT in Canada is transitioning from the military healthcare system to the civilian healthcare system. CAF members access the federally operated military healthcare system designed to support military operations during service. The military healthcare system has a high degree of integration across health sectors, facilitating access to and coordination of care. After release, veterans must navigate the civilian healthcare system, which serves a much broader population with far less integration between sectors. Learning to navigate a new healthcare system, potentially for the first time as an adult, can be challenging for newly released veterans and could aggravate transitions that are already difficult.⁴

Primary care is an important source of healthcare in both the military and civilian healthcare systems. Primary care is the first point of contact with the healthcare system that provides person- and community-focused care⁵ and is associated with better health outcomes.⁶ During service, all CAF members have consistent access to primary care providers across bases.⁷ After release, however, veterans must arrange their own primary care provider in the civilian system, and there is no guarantee they will find one in a timely fashion,⁸ especially considering ever-increasing reports highlighting the primary care crisis in Canada.^9-11 Canadian research has shown that primary care is a key source of healthcare for CAF Veterans in the civilian healthcare system^3,4,12 and that veterans are more likely to use primary care services than their civilian comparators.^3,13

It is important to note that while Veterans Affairs Canada (VAC) facilitates access to some private health services (e.g., psychologists, occupational therapists) for service-related injuries, they do not offer primary care services. Furthermore, only 19% of veterans are VAC clients.¹⁴ It is unclear how much formal support exists to prepare veterans specifically for the health service transition through VAC or the CAF.

Veterans experience some health conditions such as chronic pain, hearing problems, depression and post-traumatic stress disorder at greater proportions than the general Canadian population.¹⁵ Veterans with a medical release are more likely to report having a difficult adjustment to civilian life.¹⁶ For decades, primary care has been the gatekeeper for the public healthcare system in Canada,¹⁷ making it vital for those requiring specialist care and effectively addressing the health needs of people with chronic health conditions.¹⁸ Health system transition associated with MCT is an important issue.

While no research has specifically examined access to primary care during MCT, some general studies of MCT suggest that access to and quality of primary care may be problematic. Lee et al. found that setting up new health providers, including primary care providers, in the civilian system was the second most challenging aspect of MCT, just behind identity loss.¹⁹ In a qualitative study by the Veterans Ombudsman, Veterans reported that finding a primary care provider was challenging.²⁰ The most recent Life After Service Survey results indicated that approximately 20–35% of participants who released within the last two years did not have a primary care provider,³ far below the national proportion of 14.5% reported by Statistics Canada in 2019.²¹ This discrepancy is disconcerting, considering the first two years after release may be the most difficult.²

Access to primary care throughout the MCT process is an important consideration but has received limited attention in MCT literature, particularly in Canada. In this study, we sought to answer the research question: How do CAF members facing military release experience the impending transition from the military healthcare system to civilian primary care?

Methods

We used interview data from the first qualitative longitudinal study²² on MCT on which the first and last authors were team members. While health system transition was not the sole focus of this study, it was encompassed within the overall research purpose of examining the health and wellbeing of CAF members/Veterans throughout MCT. The data aligned well with our research question and gave us a unique opportunity to examine data from a sample not easily reproduced due to challenges associated with recruiting active CAF members[1]. Further details on the purpose and methodology of the longitudinal study can be found in the final report.²³

We conducted a phenomenological analysis of the health service and access data collected from participants before they were released from the military using data from English-speaking Regular Force Veterans. Reserve Force participants were excluded because they typically access healthcare through the civilian system during service and do not undergo the same health system transition as those in the Regular Force. Phenomenological data analysis was selected because it enabled us to specifically examine CAF members’ lived experience of health service transition. In addition, the methods used in the initial stages of data analysis (i.e., open coding), which had already been conducted, are consistent with phenomenological data analysis.²⁴ During initial coding, health and health services were identified as a category of wellbeing during MCT. These data were subject to deeper analysis to better understand participants’ lived experience of primary care transition.

Our analysis began with familiarisation of the data. Given the large sample in the longitudinal study (n=80), summaries of each interview were written to promote data familiarisation and prepare for subsequent interviews. We read these interview summaries for all included participants. Next, the data associated with the health and health services category were extracted and subjected to deeper analysis emphasising health services transition, particularly primary care. In line with phenomenological data analysis,²⁵ a textural description of the health data was created to describe what the participants experienced, then a structural description was created to describe how participants experienced the transition. These descriptions were then merged to synthesise the textural and structural descriptions—this textual-structural synthesis is the essence of the experience.²⁵ The qualitative data analysis software program MAXQDA²⁶ facilitated data analysis.

The longitudinal study was granted ethics clearance from the Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (HSREB; #6027248).

Results

A total of 80 CAF members with an impending release were interviewed between May 2018 and January 2019 with interviews lasting 60–120 minutes in length. After applying our inclusion criteria, a total of 69 interviews were analysed. Most participants were Army members (n=32) followed by Air Force (n=22) and Navy (n=15), were from non-commissioned ranks (n=47), and had at least one disaster or combat deployment (n=47). Most participants were releasing for medical reasons (n=41) and had more than 15 years of service (n=56). Most participants were male (n=49), ranging in age from 27–61 years (average: 48 years). There was representation across Canada, with most participants (n=40) coming from the central region (ON and QC) followed by Western (n=17) (BC, AB, SK and MB) and Eastern Canada (n=12) (NB, NS, PEI and NL). Three themes that encompass the participants’ pre-release experience of transitioning from the military healthcare system to provincial primary care were identified: 1) on the precipice: anticipating change; 2) making the leap: support and preparation; and 3) ‘it would be nice if …’: recommendations for improvement.

On the precipice: anticipating change

When reflecting on the upcoming transition to civilian healthcare, many participants described feelings of anxiety, and sometimes fear, driven by uncertainty around how to navigate the change.

‘That’s a big worry for me’: anxiety and fear

As participants envisioned the health services transition associated with MCT, most anticipated a significant change from the system they had become accustomed to in the CAF. Some expected the transition to civilian primary care to go smoothly and had already established informal connections with a primary care provider. Often, these participants indicated they had gotten lucky in finding a primary care provider so early in the process, which removed the uncertainty around primary care access:

‘I was very lucky that I found, um, somebody that was taking – one of those kiosk-type signs that said, ‘Taking patients.’ … I’ve heard the horror stories. Um, mine wasn’t a horror story. I can call it lucky. Just happened to be where I am currently and there was a doctor.’ (participant #48)

For many others, the impending transition to civilian healthcare elicited concern, worry, anxiety, or even fear: ‘I guess, my biggest worry is just getting proper healthcare’ (#49).

Uncertainty

The degree of uncertainty surrounding the health service transition fuelled participants’ anxiety about the transition, adding another layer of stress to the transition experience. First was the lack of clarity around the health services transition. Many participants had little idea of what to expect in the shift to civilian primary care and were unclear about the process. One such participant expressed confusion around how to find new providers in the civilian primary care system, which they had never done before: ‘I cannot emphasise strong enough, I guess, the… ambiguity I’m facing with health care … the lack of, ah, a firm, firm direction and outcome of where things are is definitely not helpful’ (#49).

Apprehension about a possible change in health service access and quality also contributed to participants’ uncertainty. Many participants said they had excellent access to primary care in the military and were expecting a decrease in ease of access after release. Many participants reported not needing to think about healthcare in the military because it was taken care of for them. Many felt out of touch with the civilian system, especially those who have spent their entire adult lives in the military. They understood things would change but did not know how long they might expect to wait for a primary care provider, and this uncertainty led to concerns about gaps in access to care after release. A participant summarised this:

‘Being a military member, you’re kind of in a fantasy land. … Like, even dealing with my kids and my wife, I think I’m a little bit out of touch with how health care works. … It’s kind of funny because the military is almost like a parent in some ways, right? So, they never really get exposed to what most of the country goes through, I’d say, for health care.’ (#82)

Apprehension about entering a new health system was also driven by concern about the potential difficulty in finding a primary care provider. Many cited nationwide shortages in primary care providers and the experiences of other veterans as the primary driver of this concern:

‘I’m a little bit stressed about finding a family doctor. Everybody else I’m pretty set up with now, I think. But a family doctor is what I need more than anything. Everything I’ve been told, it’s going to be very difficult to find one …’ (#51)

Many participants speculated about how they might access health services without a family doctor and envisioned a tedious experience with long waits in emergency departments or walk-in clinics. This was a distressing prospect for some, given the ease of access they currently have in the military healthcare system.

Many participants remarked on the abrupt loss of access to the military healthcare system, with some expressing a sense of abandonment. All participants were imminently facing the loss of their primary care provider and many were also losing mental health and other interprofessional primary care providers with whom they had built strong therapeutic relationships. Finding a new set of primary care and other healthcare providers in the civilian system meant having to re-tell one’s story to new people and establish new relationships, which was troubling for some:

‘The day you’re finished with military, you have no more access to any service that you had access to before. From that day forward, you have different services. You have, you know, like even your healthcare plan is different. Your dental plan is different. You, all these things you have to get used to that you’re not used to. It all stops … So, I think that’s a huge, huge mistake on the part of the military to withdraw all services, basically, the day you leave the military. You’re just, you are, you’re left flapping in the wind.’ #12)

Some participants also expressed concern about civilian primary care providers not understanding their unique health needs, further contributing to apprehension: ‘that’s a fear: that I’m totally afraid that some civilian doctor isn’t going to understand the military side’ (#41). The loss of primary care and other health services, as well as the threat of a possible gap in access, created acute uncertainty and distress for those with ongoing health issues.

Many participants felt that maintaining or improving their health was the key to realising a positive transition, so continuity of health services was paramount. When asked what their most important needs would be moving forward, a participant stated: ‘certainly health needs. I need to make sure I stay connected, um, with my healthcare providers, because things are constantly evolving’ (#25).

The potential disruption in continuity was disconcerting, especially for those with ongoing mental health issues who identified access to health services, including primary care, as a key future need. Participants with chronic and/or multiple health issues that require ongoing access to care expressed great concern, and sometimes fear, about the shift to the civilian healthcare system. One such participant was particularly frank:

‘Um, well, that’s the other part of a fear on, on the other side. There’s no available doctors here in, you know, [city]. So, for me, where I have a stomach issue, a back issue, a mental health issue that requires, ah, you know, ah, prescriptions … I’m worried that I’m not going to have the, ah, family doctor because, for 30 years, I’ve never had to have one. And here, locally, there’s none available. So, you’re put on a list. So, after my three months of running out with my meds, I’ve got to go sit at an Emergency Room, trying to get a replace—a, ah, replacement prescription for something that I’m about to expire. … it scares the shit out of me.’ (#69)

Participants pointed out that there is much at stake for those with health issues if they cannot find a primary care provider because they saw primary care as a vital service in managing their health issues. This was particularly salient for those with mental health issues. Participants who were receiving VAC injury/illness awards or long-term disability felt particularly stressed about finding a primary care provider to complete mandatory medical forms.

Making the leap: support and preparation

Participants pointed out that the CAF has some procedures to ensure releasing members’ health is stable. Many participants described undergoing a medical evaluation to provide an up-to-date summary of their health status: ‘The military is really good at making sure that you do what’s called a Release Medical. … to see whether or not there are any, um, issues that you’re not aware of that is actually is an issue’ (#31).

Managing MCT is a complicated and taxing endeavour, and many participants describe the substantial administrative burden they encountered during this transition. Participants describe some support from the CAF, but overall, there was a sense that they had sole responsibility for navigating the health service transition, especially for primary care:

‘There’s a social safety network around us and, all of a sudden, it feels like it’s all gone. Your – the doctor that I’ve had for 25 years, she’s gone … So, and to think that we’re going out there. And, all of a sudden, it’s like, ‘Okay, you’re on your own to find everything.’ (#43)

A few participants indicated the Second Career Assistance Network seminars[1]—known as SCAN seminars—advised them of the need to set up health services in the civilian system but reported little formal support to connect members with civilian primary care providers: ‘The Forces tells you that you need to go and do it, but they don’t help you’ (#06).

Several facilitators helped veterans prepare for the transition to civilian primary care. Some participants reported reaching out to the Military Family Resource Centre for support in finding primary care providers—specifically, the Veteran Transition Program and Operation Family Doc—with some success. Others credit case managers in the military healthcare system or the Transition Centres for providing tips and resources. Some participants’ military primary care providers referred them to civilian colleagues practising in the civilian system.

Proactive preparation was seen as an important aspect of navigating MCT, but for many, this was stymied by several barriers. Participants without informal connections to a civilian primary care provider pointed out they could not obtain provincial/territorial health insurance until after their release date, and many of the primary care providers they contacted would not accept them without it:

‘I need a doctor. Um, I can’t get a health card [inaudible] three months before I release. Ah, so I can’t get a, officially get a family doctor until after I have a health card number, so.’ (#51)

This was frustrating for many participants, especially those with a long lead up to release who could not take advantage of programs designed to help them find a primary care provider until after their release was official. Other barriers included a lack of primary care provider supply in the local region, difficulty making time to search for providers while still working full-time, and being overwhelmed with the magnitude of administrative tasks associated with MCT.

‘It would be nice if …’: recommendations for improvement

When reflecting on the expected challenges of the transition to civilian life, participants identified several ways to improve the health service transition. The most prominent was to extend access to the military healthcare system after the release date to eliminate the abrupt shift between healthcare systems, enabling veterans to maintain continuity of primary care and other services while they get set up in the civilian system:

‘The medical follow-up piece, um, would be useful. Um, if I was able to continue to, if I was, for example, being treated for my mental health, to be able to continue to access those services, at least on an interim basis for a while after releasing, would be fabulous.’ (#07)

Other participants advocated for developing a formal program to help releasing military members attach to a provincial primary care provider and to better prepare veterans for what they can expect in the civilian healthcare system. One participant pointed out that the military prepares you for military service through basic training, and there should be a similar preparation for the civilian world:

‘You’re stripped down. You’re rebuilt. You’re re-programmed. And then, you’re left to your own devices when it’s time to go out the door. … we kind of need a, you know, a few-week training to get out.’ (#70)

Some participants pointed to veterans’ special health needs and indicated that providing service through veteran-specific clinics or hospitals would be ideal:

‘The challenge with, with each person that comes out of the military, they walk into a normal civilian hospital and they’re – I’m not saying that they’re special in any way, shape or form as a human being than anybody else. But they definitely have different criteria than the average human being … If you had a veteran hospital that knew the individual, has that file there and everything and there was no guesswork, or anything, and, and that person has been going there for a while, because it is set up just for veterans.’ (#68)

The need to address veteran-specific health needs was consistently underscored across the data.

Discussion

This is the first Canadian study to examine the pre-release experiences of CAF members as they prepare for the transition from military to civilian primary care, providing important insights into MCT. For many participants, maintaining or improving their health was a key priority and continuous access to healthcare, particularly primary care, through the transition was critically important. The abrupt loss of guaranteed access to primary care through the military healthcare system, coupled with the need to make new connections with civilian clinicians independently, created the potential for a gap in access to primary care, causing anxiety among many participants. For those concerned about their current or future health, the transition to civilian health services loomed large in their minds.

Our findings are consistent with other Canadian studies that suggest finding a primary care provider after release may be difficult.^3,19,20 The Life After Service Surveys show that recently released veterans were more likely to report a difficult adjustment to civilian life than those with earlier releases,³ indicating greater difficulty with MCT for those in the peri-release period. Authors found that medical release was more strongly associated with difficult MCT than other factors (e.g., service element, rank).¹⁶ Our results provide some explanation for the difficulties faced by these subsections of the veteran population, supporting past suggestions that health service transition may exacerbate difficult adjustment.⁴

Improving veterans’ ability to proactively prepare for the health service transition is paramount. As noted earlier, data from Statistics Canada²¹ and VAC³ indicate that the proportion of newly released veterans without a primary care provider is higher than that of the national population. Unfortunately, access to primary care in the civilian system has become even more dire in the four years since Statistics Canada published their analysis. The Angus Ried Institute recently reported that one in five Canadians do not have a family doctor,²⁸ and The Canadian Broadcasting Corporation recently reported that there were two million people without a family doctor in Ontario (29), where the majority of veterans reside (30).

A recent Canadian study found that the average wait time to find a primary care provider was one year, with some waiting over three years.⁸ Many participants with ongoing health issues requiring regular care expressed apprehension about accessing health services without a primary care provider and were concerned about the possibility of having to wait long periods at walk-in clinics or emergency departments. According to research conducted on unattached Canadians with chronic illnesses, these concerns have merit. Such research has found that walk-in clinics and emergency departments were the main sources of care for unattached civilian patients^31,32 and recently released CAF Veterans.³³ The study participants found accessing care through walk-in and emergency clinics to be onerous, creating a barrier to care seeking. Indeed, primary care literature in Canada and internationally indicates that walk-in clinics and emergency departments are not ideal for accessing primary care because they lack continuity and coordination of health services—a long-term relationship with a personal primary care provider leads to better health outcomes.^31,32,34

Some participants also expressed concerns about civilian providers’ ability to understand and address their unique needs as military veterans. This aligns with findings from a recent consultation with veterans conducted by The Chronic Pain Centre of Excellence for Canadian Veterans.³⁵ Indeed, American research has identified the importance of civilian providers’ military cultural competence iii in providing effective care^36-39 with more recent work done in Canada.⁴⁰ Recent Canadian research on veterans’ health service utilisation in Ontario noted concerns about civilian primary care providers’ capacity to manage veteran health needs,¹² highlighting the importance of improving military cultural competence.

Implications

Our results reveal a gap in formal support for the primary care system transition that must be addressed. The Canadian Forces Morale and Welfare Services administers the Veteran Family program⁴¹ and provides information about healthcare access on their website.⁴² However, much of their offerings, including the Veteran Family Transition Program, are for medically releasing veterans, which accounts for only 31.2% of releasing members.³ More assistance available to a broader spectrum of releasing members is necessary because, as noted earlier, approximately 38.7% of veterans report a difficult transition, regardless of release type.

While Canadian resources to support both veteran and civilian primary care providers working with veterans are limited, The College of Family Physicians of Canada, in partnership with VAC, recently released a guidance document for primary care providers working with veterans⁴³ Calian Health has also published a guidance document for civilian healthcare providers as well as newly released veterans based on research.⁴⁴ In addition, some local CAF Transition Groups are developing programs to educate releasing CAF members on navigating the civilian health system.^45,46

There are supports in provincial healthcare systems aimed at facilitating access to health services for veterans, such as centralised wait lists for primary care providers.⁴⁷ However, many of our participants were delayed in their search for a civilian primary care provider because they would not have access to provincial health insurance until their release date. Allowing veterans to access provincial health insurance before the official release date may help bridge this gap in continuity.

It is encouraging to see some improvements in health service access for Veterans. However, more research is needed to better understand the health service transition and meaningfully inform programs and policies to support veterans during MCT. Our results are on the cutting edge of this movement and can inform future efforts to support veterans through the transition to civilian healthcare.

Limitations

Our sample contained more women and medical releases than the general CAF population. Women represent 15.5% of CAF Regular Force members,⁴⁸ while they comprise 27.5% of our sample. A specific examination of women’s MCT experiences within the longitudinal study has been done and reported elsewhere.⁴⁹ Medical releases accounted for 56.5% of our sample compared to 32% of the 2019 Life After Service Survey sample.³ While medically releasing veterans do seem to have greater difficulty with the transition, those who release voluntarily also struggle and may have challenges that are different from those of medically releasing veterans. Therefore, future studies should focus on the perspectives of CAF members/Veterans who release voluntarily.

The data used in this study were collected as part of a large longitudinal study focusing on mental health and wellbeing during MCT. While health service transition was encompassed within the overall purpose of the longitudinal, the broad focus on wellbeing may have limited the depth and nuance of the data.

Conclusion

An inherent part of MCT is the shift from military to civilian primary care—an important aspect of MCT, considering veterans have unique health needs that must be addressed in civilian primary care. This is the first study to specifically examine healthcare system transition, focusing on primary care, during MCT from a pre-release perspective. Our results align with recent research suggesting veterans may have difficulty finding a primary care provider and provide some explanation for the high proportions of difficult adjustment seen in medically and recently released veterans. Our results highlight the need for more robust supports related to the health service transition and improving military cultural knowledge among civilian primary care providers. While interest in the health service transition among releasing CAF members/Veterans is increasing, more research is needed on the healthcare system transition to increase the capacity of federal and provincial governments and primary care providers to support CAF members and Veterans through the transition to civilian life.

Declaration of interest statement: The authors have no conflict of interest to declare.