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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
2
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
9
VHA is a major contributor to the nation’s healthcare system
Healthcare
Disaster Relief
HomelessResearch
Healthcare Workforce
Provides medical care to 6 million veterans
10
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)
11
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
12
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)
13
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
15
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
17
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
18
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
47
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
65
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
66
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
67
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
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