Scaling up the Focus on Service Members, Veterans and their Families Presented by: Cicely B. McElwain LCSW-C Military and Veteran Affairs Liaison November 2016

Background and History Military Families Strategic Initiative (2010-2014) Executive Order 13625: Interagency Task Force on Military and Veterans Mental Health State interagency teams: strengthening SMVF behavioral health systems and community capacity Implementation of best practices Building workforce capacity via military culture competency training Building peer and grassroots/community capacity Increasing access to U.S. Department of Veterans Affairs (VA) services and DoD Partners SAMHSA has a long history of working to address the needs of our nation’s service members, veterans and their families. This is evident through the Strategic initiative that was identified for this population in 2010 and by the agency elevated SMVF to a population of focus when the initiative closed in 2014. Today the work of the agency in addressing the behavioral health needs of SMVF is evident in the language added to every funding opportunity that is released by each of our 4 Centers. SAMHSA Represents HHS with our federal partners and DoD and VA as part of the Interagency Task Force on Military and Veterans Mental Health ( ITF) . On August 31, 2012, President Obama signed Executive Order 13625 directing the Departments of Defense (DoD), Veterans Affairs (VA), and Health and Human Services (HHS), in coordination with other federal agencies, to take steps to ensure that Veterans, Service members and their Families receive the mental health and substance use services and support they need. It is this ongoing collaboration that has led SAMHSA to play an integral role in summits like the one here today that are taking place nationwide. SAMHSA works hard to support States and Territories to support SMVF in accessing quality behavioral health care and I am pleased to share with you some information on the structure and technical assistance efforts that we have underway.

Interagency Collaboration Military and civilian interagency collaboration is essential for strong behavioral health systems for SMVF Problems are multifaceted and cross systems Integration is essential Primary issue is not lack of services, but effectively using systems and services that currently exists or are being developed’

Vision and Mission of SMVF Efforts Our Vision: SMVF resiliency and recovery supported in every community -- the right services, right place, right time Our Mission: Enhancing the capability of public and private, military and civilian, policy makers to strengthen their behavioral health systems and address SMVF health issues We Do This By: Building ongoing relationships with states and providing quality, innovative, effective and flexible training and technical assistance programs, technologies, and products

2016 TA Highlights 65 needs assessment calls with state teams 36 TA site visits completed for the Interagency Leadership Initiative 2 In-State Policy Academies (Nebraska, New Mexico) 3 Learning Communities in 9 sessions with 36 participants from 13 states Learning Community 3 sessions held for each topic: 1.Substance Use Disorders 2. Adapting, Designing and Delivering Training for SMVF Peers 3. Supporting Children in Military and Veteran Families - Promoting Protective Factors Outcomes Highlights • The SMVF TA Center completed 38 site visits with 23 states and territories from March to September o Alabama, Delaware, District of Columbia, Guam, Hawaii, Illinois, Kentucky, Maryland, Massachusetts, Nebraska, New Hampshire, New Mexico, Nevada, North Carolina, Ohio, Oklahoma, Rhode Island, Tennessee, Texas, Virginia, Washington, West Virginia, and Wyoming • The SMVF TA Center has documented state outcomes in the following priority areas: (1) Establishing state-level leadership and infrastructure, and (2) Strengthening state-level military/civilian behavioral health service systems o States are developing action plans to address –  Obtaining governor’s support (23 states)  Forming a military/civilian interagency team (22 states)  Developing a strategic plan (19 states)  Establishing work groups that meet regularly (17 states)  Building upon related state planning efforts (21 states)  Identifying/screening the SMVF population (15 states)  Sharing and mapping interagency data (19 states)  Integrating behavioral health services systems (22 states)  Developing the workforce (23 states)

The Process Since 2008, SAMHSA has held Policy Academies to help states and territories strengthen behavioral health service systems supporting service members, veterans, and their families (SMVF). To date, 46 states, 4 territories, and the District of Columbia have participated in the Policy Academy process with the goal of developing state/territory-wide strategic plans designed to address these issues. These efforts are in 3 distinct phases.

Phase I: Policy Academies As of this year, 49 states, 4 territories, and the District of Columbia have engaged with the SMVF TA Center to completed a SMVF Policy Academy and established operational, interagency teams that: Have developed strategic plans and Receive ongoing assistance implementing best practices Read slide 8 SMVF Policy Academies 2008, 2010, 2011, 2012, 2013, 2015

Phase II: Implementation Academies 30 Policy Academy teams have completed an Implementation Academy, which builds on SAMHSA’s SMVF Policy Academies by taking strategic planning to the next level. 5 SMVF Implementation Academies 2014 Military and Veterans’ Families 2014 Justice-Involved Service Members and Veterans 2014 Suicide Prevention 2015 May Substance Use Disorders Virtual 2015 September Substance Use Disorders Virtual Implementation Academies included a topic focused approach with a smaller team size that could implement their plans in those areas.

Phase III: Interagency Leadership Initiative Initiative Goal: Improve military and civilian interagency collaboration and set direction Strengthen buy-in from the Governor’s offices and top-level leaders to integrate new stakeholders and maintain momentum and focus on this population Bring key agencies together to set future direction for SMVF given changes in current environment Develop, refine, and implement state-wide SMVF behavioral health strategic plans Integrate and implement updated state plans at a community level Invited all states and four territories to participate Reinvigorate the teams, engage with leadership that have transitioned since initial plans were in place.

Team Composition Teams are comprised of senior-level military and civilian representatives: Governors’ office representatives and tribal leaders Senior-level representatives from state/territory/tribal agencies National Guard Reserve Affairs U.S. Department of Veterans Affairs Statewide initiatives (e.g., Joining Community Forces, Community Forces, and Community Blueprint) Other stakeholders such as veteran service organizations, military and veteran family peer support organizations, and providers

PHASE I and II Policy and Implementation Academy Teams

Phase III - Leadership Participating States and Territories Alabama Alaska Arizona California Delaware District of Columbia Guam Hawaii Illinois Kentucky Maryland Massachusetts Nebraska Nevada New Hampshire New Mexico New York North Carolina Oklahoma Rhode Island South Dakota Tennessee Texas Virginia Washington West Virginia Wyoming  

The Problem Optional slides 15 to 19 depending on time allowed /audience Researchers have documented a lag between deployment and engagement in mental health treatment. A 2012 study by Maguen et al. utilizing VA medical records found a delay of over 2 years between a service members last deployment and engagement in mental health care. This was approximately 1.5 years longer than the length of time between a deployment and engagement in primary care services. At 3 years post-deployment, 75% of veterans with a mental health diagnosis that were receiving services at the VA, were not engaged in minimally adequate mental health care. The median lag between an initial mental health appointment and engaging in a course of minimally adequate mental health care was 7.5 years. In a follow up study, Maguen et al. found that delaying treatment for mental health conditions leads to increased risk for chronic functional impairment and symptoms, therefore resulting in more complex treatment needs. Further, those veterans and service members who delay treatment initiation take longer to experience symptom improvement than those who engage in treatment sooner.

Lag in Symptom Onset Lag between separation from service and onset of behavioral health symptoms1 Increased suicide risk Delayed onset post-traumatic stress disorder (PTSD) Higher patterns of family instability2 There is emerging research to suggest a relationship between military separation and onset of behavioral health symptoms. A 2015 study found that suicide risk was not significantly associated with combat deployments, but was significantly correlated to separation from military service. Further, those who separated from the military after a brief service period or received a dishonorable discharge are at even greater risk for suicide than those who separated under different conditions. A 2013 examination of military children and families found that there may be some protective factors within the military to lessen the occurrence of divorce. While they are in the military, service members are less likely than their civilian counterparts to divorce. However upon separating from the military, the trend reverses. Veterans are 3 times as likely to be divorced as those who have never served. This indicates higher patters of instability in military families one they have separated from service. 1. Reger MA, Smolenski DJ, Skopp NA, et al. Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military. JAMA Psychiatry. 2015;72(6):561-569. doi:10.1001/jamapsychiatry. 2014. 3195. 2. Clever, Molly, and David R. Segal. "The demographics of military children and families." The Future of Children 23.2 (2013): 13-39.

Broaden Healthcare Workforce The Need: Broaden Healthcare Workforce Most healthcare is received outside of the VA The behavioral health workforce therefore needs training and education to support SMVF in the community

Veterans’ Health Insurance Sources Many veterans have access to multiple sources of healthcare coverage. The largest source of healthcare coverage is employer sponsored. 25% of veterans under age 65 have multiple health care coverage types. 80% of veterans over age 65 have access to more than 1 healthcare coverage. This increase the likelihood that veterans will be seen in community based services. A VA study by Tracy Stecker found that the most common reasons veterans cited for not accessing mental health services at the VA included veteran expectation for treatment and emotional readiness. Many cited not wanting to receive PTSD treatment from the VA because they perceived that they would be encouraged to pursue a treatment course inconsistent with what they desired, such as taking medications or participating in group therapy. The other most common hesitation was a feeling among veterans that they were not ready to discuss traumatic events. This study found that stigma was infrequently cited by veterans, though stigma has historically been identified as a barrier to treatment access. The author proposes that the supportive culture toward the post 9-11 military may have reduced the perception of stigma. Logistical issues include proximity of VA to veteran and time.

Technical Assistance Opportunities TA site visits Implementation Academies Subject Matter Expert TA calls State-to-state sharing/ mentoring Webinars Learning communities Website Listserv Resource materials and fact sheets Virtual TA

How can we help? Warm Introduction to existing team members Individualized State Packets Shared resources based on gap analysis findings Inclusion in state team structure and planned events Ideas?

Contacts: Cicely Burrows-McElwain LCSW-C Military and Veteran Affairs Liaison National Policy Liaison Branch (SAMHSA) 5600 Fishers Lane, 18E01A Rockville, MD 20852 Phone: (240)-276-1111 Donna Aligata, Director SAMHSA's Service Members, Veterans, and their Families Technical Assistance Center Policy Research Associates, Inc. 345 Delaware Avenue Delmar, NY 12054 Phone: 518-439-7415