It’s Not Your Father’s VA

Lucile Burgo MD

Stephen Hunt MD, MPH

VHA POST DEPLOYMENT INTEGRATED CARE INITIATIVE

Objectives• Understand what is available at the VA for eligible

Veterans for the treatment of chronic co morbidities for chronic pain such as substance use disorder, PTSD, depression and traumatic brain injury

• Understand the value of collaborative approaches to readjustment and recovery for patients recently deployed

• Learn about the VA and how to partner with and access services and resources necessary for optimal, post-war health for all Veterans

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VA 101

How many veterans are there currently in the United States?

How many veterans are there currently in the United States?

A – 5 MillionB – 11 MillionB – 17 MillionC – 22 MillionD – 34 Million

MEDAL of HONOR

If we ask these young men and women to risk life and limb in the service of our country we must be prepared to serve them. They are the heroes of America. They deserve the best our society has to offer, including recognition for doing what no one wants to do, and most would not try to do.

Sgt 1st Class and Army Ranger Leroy Arthur Petry is honored for conspicuous gallantry with the prestigious Medal of Honor by President Obama on July 12th, 2011

Integrated Post-Combat Care

Community Providers

Collaborate with local VA facilities/Vet Centers/community resources

Integration of care:medical servicesmental health services: screen for

co-morbid conditions, addresschronic pain, TBI, sleep

social services: family, job, educational, financial

Culturally sensitive caremilitary culture: acknowledge servicecombat culture: acknowledge sacrifice

Nationwide Community of Care for Returning Combat Veterans and Their Families

Veterans Administration

VHA Veterans Health Administration

Provides medical exams and healthcare

VBA Veterans Benefits

AdministrationAdministers benefits

CemeteriesBurials

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VHA is a major contributor to the nation’s healthcare system

Healthcare

Disaster Relief

HomelessResearch

Healthcare Workforce

Provides medical care to 6 million veterans

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LARGEST INTEGRATED HEALTH CARE SYSTEM IN THE COUNTRY

153 Hospitals

50 Domiciliary Resident Rehabilitation Treatment Programs

232 Readjustment Counseling Centers

VET CENTERS

134 Community Living Centers

951 Clinics (Hospital, Community-Based, Independent and Mobile)

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Provides medical care to 6 million veterans

Healthcare

Disaster Relief

HomelessResearch

Healthcare Workforce

Serves as the largest single provider of

health professional training in the world

VHA is a major contributor to the nation’s healthcare

system

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250,000+ Employees

19,000+ Physicians 6,000+ Pharmacists 3,000+ Psychologists 50,000+ Nurses 900+ Dentists

109,000+ health trainees (> 30,000 Med Res, 20,000 Med Students, 500 Dental Res, 50,000 Associated Health Professions in 2008)

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Provides medical care to 6 million veterans

Serves as the largest single provider of

health professional training in the world

Healthcare

Disaster Relief

HomelessResearch

Healthcare Workforce

One of the largest and most productive

research organizations in the country

VHA is a major contributor to the nation’s healthcare system

VA Research Highlights

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Radioimmunoassay

Nicotine Patch

ALLHAT

First Liver Transplant

Shingles Vaccine Efficacy

Prosthetic Limbs

Deep Brain Stimulators in Parkinson’s

ASA in MI Prevention

Genomic medicine

Evidence Based PTSD RX

Implantable Cardiac Pacemaker

Lutein for Mac Degeneration

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Provides medical care to 6 million veterans

One of the largest and most productive

research organizations in the country

Serves as the largest single provider of

health professional training in the world

Healthcare

Disaster Relief

HomelessResearch

Healthcare Workforce

Largest direct care provider for

homeless persons in the country

VHA is a major contributor to the nation’s healthcare system

Secretary Shinseki’s 5 year Plan

• >30% of nation’s homeless are Veterans

• VA is taking decisive action to end Veteran homelessness in five years. All Veterans at risk for homelessness or attempting to exit homelessness must have easy access to programs and services. VA offers a variety of resources, programs, and benefits

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Provides medical care to 6 million veterans

Largest direct care provider for

homeless persons in the country

One of the largest and most productive

research organizations in the country

Serves as the largest single provider of

health professional training in the world

Healthcare

Disaster Relief

HomelessResearch

Healthcare Workforce

Principal Federal asset for medical

assistance in large-scale disasters

VHA is a major contributor to the nation’s healthcare system

Disaster Assistance Hurricane Katrina(National Response Plan)

18 VA Federal Coordinating Centers were activated

Mobilized $1.3 million in critical pharmaceuticals and medical supplies

VA deployed mental health professionals and provided space for a 250 bed medical shelter at the VA in Alexandria, Louisiana

VA employees evacuated 166 patients before the storm hit

The VA electronic health record supported continuity of comprehensive care for evacuated Veterans

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WHO are our Veterans today and in the future?

22,658,000 U.S. Veteran

Population (8% female)

8.4 million are enrolled in our

system 6 million patients received VHA

health care in 2010

73.0 million outpatient visits

Over 662,000 admissions

annually The number of women Veterans will double in the

next 5 years.The number of Veterans 85 years and older is more than 1.3 million.

VHA Primary Care by Age & Gender

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

<25 25-34 35-44 45-54 55-64 65-74 75-84 85-up

Mill

ion

pati

ents

Age

Female Male

44%

25%8% Female

21% had encounter in Mental Health

57 y/o female bus driverwith breast cancer

82 y/o male with dementia, recently widowed

68 yo male social workerCHF, hep C, depression

27 yo female office worker with

PTSD, 24th week IUP

42 yo female shopkeeper

with MS

60 yo malelawyer with HIV/AIDS

complications

41 yo male accountantwith obesity and DM

What do all of these patients have in common?

36 yo male nurse with labile HTN

KOREA

WWII

VIETNAM

IRAQ

GULF WAR I

KOSOVO

SOMALIA

They are all VeteransBut you won’t know unless you ask!

AFGHANISTAN

How will I know if someone is a Veteran?

What Do Veterans Look Like?

I should not ask, it might upset them.

What do I say if they were in combat?

I don’t agree with this war and can’t hide those feelings!

They would tell me if they wanted me to know.

Web Survey of 319 primary care and mental health providers in rural communities

• 56% of community providers do not ask their patients about military service

• Only 29% of community providers feel they know how to refer a Veteran to a VA for medical or mental healthcare services

• Community providers report less knowledge in treating PTSD, TBI and substance abuse/dependence than depression and suicidality

• More than half (58%) wanted to know more about eligibility requirements for VA care

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We won’t understand how their service has impacted their lives and their health unless

we ask!“I appreciate your service and your sacrifice.

I want to hear your story”

• They may be new to your practice • They may not think it relevant to their healthcare• They may prefer to forget that time in their lives• They may be very proud• They may be reluctant to share their stories• They may think others need help more

Tune in to Military Culture

Mission Driven:

To care for those who have borne the battle and for their families and loved ones

CORE VALUES

Duty ▪ Honor ▪ Country

What does it mean to be a Veteran?

ASK ▪ LISTEN ▪ LEARN

Cultural Competency

•

The Beginning of Lifelong Training

Who wears these uniforms?

Navy

Army

Air Force

Coast Guard

Marines

Women Who Serve

• World War II 1941-1945• Korean War 1950-1953• Vietnam 1961-1975• Grenada 1983• Panama 1989• First Gulf War 1990-1991

History of Recent Conflicts

History of Recent Conflicts

• Somalia 1993• Bosnia 1993-1995• Kosovo 1998-1999• Operation Enduring Freedom (OEF)

2001-Present

• Operation Iraqi Freedom (OIF)2003-2011

• Operation New Dawn/OND2011-Present

Difference BetweenCONFLICTS & STRESSORS

• Length of Conflict• Threat• Weapons• Individual Protective

Equipment• Types of Missions• Environmental

Exposures• Casualties

• Courage• Leadership Under Fire• Unit Cohesion/Sense of Purpose

and Mission/Camaraderie• “Never Leave a Soldier Behind”• Confidence• Dedication/Sense of Pride• Maturity - sense of family

appreciation

Positive Influences in Combat & Deployments

Military History

• Branch• Dates in service

o Guard or Reserve status • Deployments: location/dates• What they were trained to do? What did they do?• How did service affect them?

o Combat and environmental exposures o Illness/Injuries during deploymentso Impact on familyo Post military plans/goals

What we are saying to the veteran.

“It means a lot to us that you are a Veteran.We appreciate your service and your sacrifice.

We want to hear your story.”

The environment of war

What are the health concerns of OEF/OIF/OND veterans seen in the VA?

• Musculoskeletal 56.0%• Mental disorders 52.0%• Symptoms/signs 51.0%• Nervous system (hearing) 44.0%• GI (dental) 35.7%• Endocrine/Nutrition 31.4%• Injury/Poisoning 28.5%• Respiratory 25.7%

VHA Office of Public Health and Environmental Hazards December 2011

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1,396,477 of the 2.25 million deployed are separated and eligible for VA care53% have been seen in VA between FY02 and December 2011

54% are former active duty and 46% are reserve and national guard

Co-morbid Concerns in Combat Veterans

CLARK- 2009

Overall prevalence inPolytrauma population:Pain 81.5%TBI 68.2%PTSD 66.8%

PTSD

TB

I

PA

INTBI/Pain

TBI/

PTSD

Pain

/PTS

D

PTSD, TBI, Pain

Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009 JRR&DSample = 340 OEF/OIF outpatients at Boston VA

5.3%

2.9%

16.5%

10.3%

12.6%

6.8%42.1%

Non-combat injury

Mentalhealth

Non-combatillness Post-combat

symptomsSpiritual /existentialstruggles

Combat injury

TBIMarital/family

financialdifficulties

Environmentalexposure

illness

Hearing losstinnitus

C&P needs

Post-Deployment Health Care Needs

Non-combat injury

Mentalhealth

Non-combatillness Post-combat

symptomsSpiritual /existentialstruggles

Combat injury

TBIMarital/family

financialdifficulties

Environmentalexposure

illness

Hearing losstinnitus

C&P needs

Post-Deployment Integrated Care

Clinical Pearls for Care of Combat Veterans1. Take a military service history

• Tell me about your military experience and how it affected you?• What was your job and where did you serve?• Did you see combat, enemy fire, or casualties?• Were you sick, wounded, injured or hospitalized?• Were you exposed to blasts?

2. Express gratitude for service and sacrifice

3. Understand barriers to care: stigma/family/work/school

o Psychological symptoms as barriers• PTSD: avoidance• Depression: low motivation/apathy• Substance use disorders: denial, poor adherence• Mild TBI: poor concentration and memory

Clinical Pearls for Care of Combat Veterans

4. Mild to moderate readjustment difficulties • Monitor for progression• Assess for sleep disturbance, • Screen for substance abuse• Ask about relationship/work/school issues

o Close follow-up, involve familyo Focus on function • Ask how they are doing• Ask how are their relationships, their job, school

o VA Post Deployment Program Managers can help with community and VA coordination of services

Clinical Pearls for Care of Combat Veterans

5. Musculoskeletal pain• Co-morbid mental health conditions lower pain thresholds. • Effective treatment strategies must address both. • Reserve opiates for select/refractory cases given high risk for substance

misuse/abuse. • Utilize interdisciplinary approach and NSAIDS, physical therapy and

complementary and alternative medicine strategies

6. Sleep • Sleep hygiene • prazosin for nightmares(1-2mg15mg qhs); • consider stepped approach Benadryl trazodone ambien

7. PTSD • psycho education, engagement• destigmatize mental health care, • referral for evidence based therapy. • Start SSRI, avoid benzodiazepines

OEF/OIF/OND Program

• Outreach• Transition• Intake• Triage• Case Management• Care Coordination

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Benefits for Returning Iraq and Afghanistan Veterans

5 Years of Cost Free Comprehensive Health Care for preventive health and any condition related to their service

Service connected conditions ensure continued care after the initial 5-year period

180 day dental benefit: one time dental care within 180 days of separation

Returning service member program managers are available for assistance, liaison and information at each VA facility Locate a Post Deployment Team

Local Vet Centers help Veterans and families with free readjustment counseling and outreach

• http://www.vetcenter.va.gov/media/confessions/confessions.asp

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Vet Center Video

Resources to support health recovery The new Post 9/11 GI Bill pays

benefits while in an approved education or training program.

• Veterans Employment Coordination Service can assist with jobs (Veteran preference for federal employment)

• VA Caregiver Support Services • Life Insurance , Home Loans, Survivor

Benefits, Vocational Rehabilitation • Homeless Services• Prosthetic and Sensory Aids• Pregnancy services

• Joining Forces is a nation-wide initiative launched by First Lady Michelle Obama and Dr. Jill Biden to honor, recognize and support veterans, service members and their families.

• The initiative calls on all sectors of society – individuals, businesses, communities, non-profits and faith-based institutions – to give our nation’s Veterans and their families the support that they so desperately need and so deeply deserve.

Joining Forces

RECENT ARTICLES

http://www.cdc.gov/pcd/issues/2012/11_0116.htm

http://www.springerlink.com/content/507463m555185p7l/?MUD=MP

Integrated Post-Combat Care

Physical Psychological

Veteran

Psychosocial

Integrated Post-Combat Care

Primary Care Mental Health

Veteran

Social Worker/Case Manager

Integrated Post-Combat Care

Community Providers

Collaborate with local VA facilities/Vet Centers/community resources

Integration of care:medical servicesmental health services: screen for

co-morbid conditions, addresschronic pain, TBI, sleep

social services: family, job, educational, financial

Culturally sensitive caremilitary culture: acknowledge servicecombat culture: acknowledge sacrifice

Nationwide Community of Care for Returning Combat Veterans and Their Families

Clinical Pearls for Care of Combat Veterans1. Take a military service history

• Tell me about your military experience and how it affected you?• What was your job and where did you serve?• Did you see combat, enemy fire, or casualties?• Were you sick, wounded, injured or hospitalized?• Were you exposed to blasts?

2. Express gratitude for service and sacrifice

3. Understand barriers to care: stigma/family/work/school

o Psychological symptoms as barriers• PTSD: avoidance• Depression: low motivation/apathy• Substance use disorders: denial, poor adherence• Mild TBI: poor concentration and memory

Clinical Pearls for Care of Combat Veterans

4. Mild to moderate readjustment difficulties • Monitor for progression• Assess for sleep disturbance, • Screen for substance abuse• Ask about relationship/work/school issues

o Close follow-up, involve familyo Focus on function • Ask how they are doing• Ask how are their relationships, their job, school

o VA Post Deployment Program Managers can help with community and VA coordination of services

Clinical Pearls for Care of Combat Veterans

5. Musculoskeletal pain• Co-morbid mental health conditions lower pain thresholds. • Effective treatment strategies must address both. • Reserve opiates for select/refractory cases given high risk for substance misuse/abuse. • Utilize interdisciplinary approach and NSAIDS, physical therapy and complementary and

alternative medicine strategies

6. Sleep • Sleep hygiene • prazosin for nightmares(1-2mg15mg qhs); • consider stepped approach Benadryl trazodone ambien

7. PTSD • psycho education, engagement• destigmatize mental health care, • referral for evidence based therapy. • Start SSRI, avoid benzodiazepines

Presumptive Benefits

Certain categories of Veterans may have conditions that are presumptively considered service connected

Agent Orange-exposed VeteransAny Vietnam Veteran who served in country is now

considered exposed to Agent Orange

Gulf War Veterans with undiagnosed or unexplained chronic illnesses

Ionizing radiation-exposed VeteransFormer Prisoners Of War (POW)

Agent Orange Presumptives

Type 2 diabetes mellitus Ischemic heart disease Prostate cancer Hodgkin's disease, non-

Hodgkin’s lymphoma Multiple myeloma Respiratory cancers Peripheral neuropathy Chronic lymphocytic

leukemia Spina bifida in children Parkinson’s disease

It is not all or nothing!• 50-70% of all Veterans are co-managed

with the private sector• VA and community providers can

partner to provide good Veteran centric care

• Veterans are means tested for co-pay status for visits and medications

$15 primary care visit, $50 specialty visit$9 per med/month

Web-Based Applications

AfterDeployment.org

MilitaryKidsConnect.org

SuicideOutreach.org

Mobile Applications

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Breathe2RelaxBreathe2Relax is a portable stress management tool utilizing hands-on diaphragmatic breathing exercise. Breathe2Relax uses state-of-the-art graphics, animation, narration, and videos to deliver a sophisticated, immersive experience for the user.

Features:• Initial setup guide to assist with tailoring application• Customizable backgrounds and music• Immersive tutorial videos• Body scanner to display effects of stress• Graphing to track effectiveness• Audio narration

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PTSD CoachT2 collaborated with the VA's National Center for PTSD to develop this app to assist Veterans and Active Duty personnel (and civilians) who are experiencing symptoms of PTSD. It is intended to be used as an adjunct to psychological treatment but can also serve as a stand-alone education tool.

Features:• Self-assessment of PTSD Symptoms• Tracking of changes in symptoms• Manage symptoms with coping tools• Assistance in finding immediate support• Customized support information

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mTBI Co-occurringConditions Toolkit

Features:• Guidance to primary care providers on the assessment and management of patients synthesizes information from the following VA/DoD CPGS: mTBI, PTSD, depression, chronic opioid therapy and substance use disorder

New Ways to ConnectResources to Support Health Recovery

LISTEN, LEARN and LOCATE

WEB Resources

• Public VA site with comprehensive information and links for our Returning Service Members http://www.oefoif.va.gov/

• VA Mental Health services: http://www.mentalhealth.va.gov/• PTSD care with information for Veterans and for Providers:

http://www.ptsd.va.gov• Wellness resources for the military and veteran community:

http://www.afterdeployment.org now with a provider portal • VA/DoD Clinical Practice Guidelines : PTSD, TBI, MUS, PAIN• The National Resources Directory (NRD) provides access to

services and resources at the national, state and local levels that support recovery, rehabilitation and reintegration: http://www.nationalresourcedirectory.gov/

• VA has gone mobile to read and share VA information, news stories find facilities on the go: http://m.va.gov/

• Information on environmental and occupational hazards during military: http://www.publichealth.va.gov/exposures/

Connecting: Doubts Video

http://youtu.be/rKzN2yI5DTU

It’s Not Your Father’s VA

Lucile Burgo MD

Stephen Hunt MD, MPH

VHA POST DEPLOYMENT INTEGRATED CARE INITIATIVE