1. Bridging the GAP: Connecting Veterans to Care Harold Kudler, M.D. Chief Consultant for Mental Health US Department of Veterans Affairs, Washington DC, USA Harold.Kudler@VA.GOV 0

2. This presentation reflects the views of its author rather than those of the US Department of Veterans Affairs This presentation reflects the views of its author rather than those of the US Department of Veterans Affairs 1

3. VETERANS HEALTH ADMINISTRATION Lessons from WW I Much of history of American Psychiatry including its approach to deployment Mental Health began with Thomas Salmon, M.D. In 1903 joined the US Public Health Service Began examining new immigrants at Ellis Island Pressed for new ways to evaluate immigrants with mental illness Briefly suspended for “insubordination” in 1907 2

4. VETERANS HEALTH ADMINISTRATION Mental Hygiene Meets Shell Shock Because of his expertise in the statistical measurement of psychiatric illnesses and advocacy for the mentally ill, Salmon became the first Executive Director of the National Committee for Mental Hygiene (1915) This program was funded by the Rockefeller Foundation- an early and important model for public/private partnership in support of Service Members, Veterans and their families 3

5. 4 https://archive.org/ details/caretreatme ntofm00salmrich

6. VETERANS HEALTH ADMINISTRATION Salmon’s Plan The Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the British Army, War Work Committee of the National Committee for Mental Hygiene, New York, 1917. http://www.nlm.nih.gov/exhibition/ emotions/psychosomatic.html 5

7. VETERANS HEALTH ADMINISTRATION The US Department of Veterans Affairs Health System At A Glance 150 Medical Centers 819 Community-Based Outpatient Clinics – Each with Primary Care and Mental Health services – Integrated health model 300 Vet Centers – Community-Based, readjustment programs staffed largely by Veterans – 50 Mobile Vet Centers – 100 Global War on Terror Outreach Workers for peer outreach Second Largest Cabinet Agency Nation’s largest medical training program Home of the National Center for PTSD 6

8. VETERANS HEALTH ADMINISTRATION Some Lingo OEF- Operation Enduring Freedom/Combat Operations in Afghanistan OIF- Operation Iraqi Freedom/Combat Operations in Iraq OND- Operation New Dawn/Current Post-Combat Operations in Iraq AD- Active Duty Component RC- Reserve Component including National Guard and Reserve troops 7

9. VETERANS HEALTH ADMINISTRATION 8 Mental Health Among OEF/OIF/OND Veterans As of September 30, 2014, 1,866,128 OEF/OIF/OND Veterans were eligible for VA care – ~60% Former Active Duty – ~40% Reserve and National Guard 60% of AD and RC have sought VA care The OEF/OIF/OND Veterans who accessed care during FY 2014 comprise 10% of the ~6.6 million individuals who received VA health care that year VA Health Care Utilization among OEF/OIF/OND Veterans Cumulative from 1st Qtr FY 2002-4th Qtr FY 2014, Released January 2015 http://www.publichealth.va.gov/docs/epidemiology/healthcare- utilization-report-fy2014-qtr4.pdf

10. VETERANS HEALTH ADMINISTRATION Mental Health Among OEF/OIF/OND Veterans Possible mental health problems reported among 56.9% of OEF/OIF/OND Veterans who have presented to VA Provisional MH diagnoses include: – PTSD 351,422 (31% of all who presented to VA) – Depressive Disorder: 282.565 – Affective Psychoses 177,597 – Neurotic Disorders: 269,151 – Nondependent Abuse of Drugs: 63,205 (Not Counting Tobacco Use Disorder) – Alcohol Dependence: 82,055 – Drug Dependence 47,374 9

11. VETERANS HEALTH ADMINISTRATION Our Focus: Deployment MH 19 PTSD TBI Depression Grief COSI SUD MST Homeless Job

12. VETERANS HEALTH ADMINISTRATION Yet Most Veterans Will Not Receive Care Through VA 22 Million Veterans 9.1 Million VA enrollees 6.6 Million users of VA healthcare Among those using VA healthcare, up to 75% are simultaneously obtaining some component of care in community settings outside of VA The vast majority of family members are ineligible to receive VA MH care Regardless of how large or expert VA may be, it cannot accomplish its mental health mission alone 11

13. VETERANS HEALTH ADMINISTRATION Veterans Access, Choice, and Accountability Act of 2014 Recent concerns about the ability to obtain prompt access to VA care across the nation led to the August 2014 passage of the Veterans Choice Act Designed to help VA expand current capacity and assure that all Veterans have timely access to high quality health care wherever they seek help Includes $10 billion to purchase care in the community for Veterans who either live more than 40 miles from the nearest VA facility or who would have to wait more than 30 days for an appointment Based on the assumption that access to Mental Health care is available in the community Likely to demonstrate that most US communities lack the capacity to deliver comprehensive mental health services – VA as “the canary in the coal mine” 12

14. VETERANS HEALTH ADMINISTRATION Where Are Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Veterans and their Families Coming Home To? 13

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16. VETERANS HEALTH ADMINISTRATION Are Community Providers Ready to Recognize and Triage the Health Care Needs of Servicemembers, Veterans and their Families? 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” Kilpatrick, D. G., Best, C. L., Smith, D. W., Kudler, H., & Cornelison-Grant, V. (2011). Serving those who have served: Educational needs of health care providers working with military members, veterans, and their families. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research & Treatment Center. Available at: http://www.mirecc.va.gov/docs/visn6/Serving_Those_Who_Have_Served.pdf http://www.mirecc.va.gov/docs/visn6/Serving_Those_Who_Have_Served.pdf 15

17. VETERANS HEALTH ADMINISTRATION Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families Cultural Competence a Key Factor in Facilitating Care for Veterans and Their Families – Providers who work primarily in a military or VA setting were significantly more likely to meet criteria for culturally competence (70 percent) – Only 24 percent of TRICARE Providers met criteria – Only 8 percent of other community providers met criteria Overall, Few Civilian Providers Are Prepared to Serve Military Populations – Only 13 percent of surveyed civilian providers met all the readiness criteria – Providers who met the threshold for cultural competency did not necessarily meet the other threshold for providing evidence-based care – Providers who work primarily in a military or VA setting were significantly more likely to meet all criteria than providers who do not 16 Terri Tanielian, Coreen Farris, Caroline Epley, Carrie M. Farmer, Eric Robinson, Charles C. Engel, Michael Robbins, Lisa H. Jaycox http://www.rand.org/pubs/research_reports/RR806.htmlhttp://www.rand.org/pubs/research_reports/RR806.html

18. VETERANS HEALTH ADMINISTRATION Keys to Military/Veteran-Friendly Practices & Health Systems (BUT More Honored in the Breach?) 1.Ask each patient “Have you or someone close to you served in the military?” – Train current providers Joining Forces and VHA Partnerships with American Association of Colleges of Nursing and American Nursing Association American Academy of Nursing Initiative – Include in all health provider training programs Association of American Medical Colleges Initiative 2.Flag military experience (including military family status) in medical records – Meaningful Use – New Current Procedural Terminology (CPT) Code for Military History 3.Train all staff on military cultural competence and deployment mental health – DoD/VA Military Culture Training for Health Care Professionals https://vha.train.org 17

19. VETERANS HEALTH ADMINISTRATION Keys to Military/Veteran-Friendly Practices & Health Systems (BUT More Honored in the Breach?) 4.Provide Community Providers with Training and Support – VA Community Provider Toolkit http://www.mentalhealth.va.gov/communityproviders – National Center for PTSD Consultation Program http://www.ptsd.va.gov/professional/consult/ – Center for Deployment Psychology http://deploymentpsych.org/ 5.List Community Providers/Programs in the National Resource Directory (https://www.ebenefits.va.gov/ebenefits/nrd) so that they are accessible to:https://www.ebenefits.va.gov/ebenefits/nrd – Veterans and family members in need of referral – Providers, employers, college officials, congregational leaders, law and court offices and other stakeholders seeking consultation or referral 18

20. VETERANS HEALTH ADMINISTRATION VA’s Unique and Essential Mission VA is distinguished by its institutional memory and unique mission of care and research on behalf of Veterans No one else owns this mission or could own it Even if Military/VA/Community Partnerships were optimally successful, the Nation would still depend on VA to preserve a common theory, a common language and the institutional memory required as the crucial link in a national system in service to Veterans and their families 19

21. VETERANS HEALTH ADMINISTRATION QUESTIONS? Harold.Kudler@VA.GOV 20