Rural Community Providers and Veteran-Centered Care: Working with VA’s Rural Health Program

Harold Kudler, M.D. Associate Director, VA Mid Atlantic Health Care Network Mental Illness Research Education and Clinical Center (VISN 6 MIRECC)

Clinical Lead, VISN 6 Rural Health

Associate Professor, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center

Harold.Kudler@va.gov

What the Data Tells Us About Our National Capacity to Manage Deployment-Related Mental Health Issues • Of 22.2 million living Veterans, 8.3 million

(37%) are enrolled in VA Healthcare • Nearly three-quarters served during a war or

an official period of conflict

• VA currently provides health care to 6.2 million veterans (28%)

www.va.gov

OEF/OIF/OND Veterans In VA

•As of December 31, 2012: • 1.6 million of 2.5 million total OEF/OIF/OND

Veterans eligible for VA services

• 56% (899,752) have already sought VA care

• Three most common health issues: • Musculoskeletal

• Mental Health

• Symptoms, Signs and Ill-Defined Conditions

http://www.publichealth.va.gov/epidemiology/reports/oefoifond/health-care-utilization/index.asp

Mental Health among OEF/OIF/OND Veterans

• Possible mental health problems reported among 54% (486,015) of the 899,752 eligible OEF/OIF/OND Veterans who have presented to VA

• Provisional MH diagnoses include:

PTSD (29% of all who presented to VA) 261,998

Depressive Disorder 205,221

Affective Psychoses 123,772

Neurotic Disorders: 181,892

Alcohol Dependence: 59,081

Nondependent Abuse of Drugs: 42,592

Tobacco Use Disorder 128,792

Our Focus: Deployment MH

PTSD

TBI Depression

Grief Family

SUD

MST

Homeless

Job

Chronic Pain

The Rural Dimension

•Rural Veterans •41% of all VA enrollees •39% of enrolled OEF/OIF/OND

Veterans •53% of Veterans in VISN 6

•Rural Service Members (including Guard and Reserve) and their families are less likely to have access to a local mental health professional

Beyond the DoD/VA Continuum

• Ideally all deployment-related Mental Health problems would be picked up somewhere within the DoD/VA continuum of care but:

•Despite their historic level of engagement in VA, if 56% of OEF/OIF/OND Veterans eligible for VA care have come to VA where are the other 44%?

Comparison to the National Vietnam Veterans Readjustment Study

•Perhaps we should only be concerned about those who choose to seek care but: • Only 20% of the Vietnam Veterans with PTSD

at the time of the study had EVER gone to VA for Mental Health Care yet:

• 62% of all Vietnam Veterans with PTSD had sought MH care at some point

Kulka et al. 1990, Volume II, Table IX-2

92535 AD Members

208,657 Dependents

24, 037 RC Members

Service Members, Veterans and their Families are Distributed Across the Entire Nation and Many Seek Care Within Their Own Communities

• An estimated 40-75% of OEF/OIF/OND Veterans seen in DoD/VA also receive part of their care in the community

• Family members also deal with deployment-related stress and virtually all of them seek care in the community

• Are Community Providers and Programs prepared to identify, treat or triage deployment-related mental health problems?

Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members, Veterans, and their Families

• Web-based survey of 319 rural and urban community mental health and primary care providers

• Available at VA Intranet Link: http://www.mirecc.va.gov/docs/visn6/Serving_Those_Who_Have_Served.pdf

• Funded by VA’s Office of Rural Health

Kilpatrick, D.G., Best, C.L., Smith, D.W., Kudler, H., & Cornelison-Grant, V. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research & Treatment Center, 2011

Participants • 97.6% participation rate among 327 providers

who opened link

• Two-thirds were mental health professionals

• Psychologists were most prevalent group followed by psychiatrists, social workers/ other mental health professionals

• Remainder self-identified as primary care providers or other professionals

• Most prevalent were family medicine providers followed by pediatricians and internists

• One-third (34%) self-described as Rural

• 6% were not sure if Rural or Urban

Experience with Military/Veterans: Military Cultural Competence

• Only one out of six (16%) providers had ever served in the Armed Forces including the Reserves or National Guard

• Although VA is a national leader in provider training, only one third (31%) had any VA training

• Only one out of eight (12%) have ever been employed as a health professional in VA

Key Findings of Serving Those Who Have Served

• 56% of community providers don’t routinely ask their patients about being a current or former member of the Armed Forces or a family member

• Only 29% of providers agreed with the statement: “I am knowledgeable about how to refer a Veteran for medical or mental health care services at the VA”

Disparities in Knowledge and Confidence Among Community Providers: Rural Matters!

• Rural Providers were significantly more likely to be primary care professionals

• No significant difference in military service but Rural providers were significantly less likely to have been employed by VA

• A significantly smaller percentage of Rural Providers said they routinely screened their patients for Military, Veteran or family status

• 37% of Rural vs. 47% of Non-Rural

Disparities in Knowledge and Confidence Among Community Providers: Rural Matters!

• Rural Providers were significantly more likely than Non-Rural providers to report knowledge and/or competence problems in treating:

• PTSD

• Depression

• Substance abuse/dependence

• Suicidality

Needed: On behalf of Service Members, Veterans

and their families:

Military and Veteran friendly

principles and practices as part of a

public health intervention

Treating the Invisible Wounds of War www.aheconnect.com/citizensoldier

• Free, accredited on-line trainings:

• Military Families

• Deployment Mental Health

• Deployment Primary Care

• Women Veterans

• Employment Assistance Programs

• 14,000+ community providers and stakeholders have completed at least one training

• New National AHEC Grant to train 7,000 more community providers

• Searchable Provider Database at www.WarWithin.org

• 1,500+ providers nationally • 1,200+ providers in NC

• -- 96 of 100 NC counties • Developed by the Citizen Soldier Support

Program in partnership with the VISN 6 MIRECC

Keys to Building Military-Friendly Practices & Health Systems

1. Ask each patient “Have you or someone close to you served in the military?”

• Train providers/students to ask

• Association of American Medical Colleges (AAMC)

• Incentivize

• NC BC/BS as a model, replicable project

2. Flag military experience (including military family status) in medical record

• EHR Aspect of AAMC Project/Meaningful Use

3. Train all staff on military cultural competence and basic deployment mental health

• DoD/VA Free On-Line Training

Keys to Building Military-Friendly Practices and Health Systems

4. Connect providers with support on military medical issues including

• www.aheconnect.com/citizensoldier

• Defense Centers of Excellence

• VA National Center for PTSD

5. List trained providers/programs in a national referral database accessible to:

• Warfighters and family members in need of referral

• Providers, employers, college officials, congregational leaders and other stakeholders seeking consultation or to make a referral

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1.Have you or someone close to you served in the military? 2. When and where did you/he/she serve? 3. What do/did you/he/she do in the military? 4. Has your/his/her military experience affected your: a. Physical Health?

b. Mental Health? c. Family? d. Work?

e. Other aspects of your life? (If your patient answers “Yes” to any of these questions, ask:

“Can you tell me more about that?” )

Draft Version of the First 4 Questions from the VA Office of Academic Affiliations Military Health

History Pocket Cards (http://www.va.gov/oaa/pocketcard/)

As They Might be Adapted for Use in an Electronic Health Record

Key VA Websites for Community Providers • http://www.mentalhealth.va.gov/

communityproviders • New from VA Office of Mental

Health • http://maketheconnection.net • For Veterans, families and

providers • http://www.ptsd.va.gov/ • VA’s National Center for PTSD

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The Big Blue Button

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Health on the Homefront:

Outreach to Rural Communities

VISN 6 Rural Health Program Improving access and quality of care for enrolled rural and highly rural Veterans by developing evidence-based policies and innovative practices to support their unique needs

Health on the Homefront:

Outreach to Rural Communities

Veteran-Centered Rural Health

• Leverage collaboration with the Virginia Wounded Warrior Program (VWWP) to establish effective engagement of Rural Veterans, their families and their health care providers (Primary Care AND Mental Health)

• Outreach conducted by innovative, dedicated VA teams at each VAMC working in coordination with VWWP staff and community stakeholders

• Educate Veterans and their community providers about military culture, deployment stress, VA resources and evidence-based management of chronic diseases including diabetes, hypertension and hyperlipidemia

Health on the Homefront:

Outreach to Rural Communities

OUR VISION Within 3 years, VISN 6, in partnership with the Virginia Wounded

Warrior Program, will have cultivated effective collaborations with community health providers and other community systems across the Commonwealth in order to provide rural Veterans with ready

access to high quality, problem-focused health education and coordinated, Veteran-Centered care

The Goal There will be

No Wrong Door

to which ANY Service Member, Veteran or family member can come

for the right help

With your help, this is an

achievable goal!

QUESTIONS?