This document provides information about integrated post-combat care available through the VA for eligible veterans. It begins with an overview of the VA healthcare system and resources available. It then discusses the high prevalence of conditions like chronic pain, PTSD, depression and TBI in recent combat veterans. It emphasizes the value of collaborative, culturally-sensitive care that acknowledges a veteran's military service and sacrifices. It provides guidance on understanding military culture and asking about a patient's service to fully address their health needs.

1. It’s Not Your Father’s VA
Stephen Hunt MD, MPH
Lucile Burgo MD
VHA POST DEPLOYMENT
INTEGRATED CARE INITIATIVE

2. 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

3. VA 101

4. How many veterans are there
currently in the United States?

5. How many veterans are there
currently in the United States?
A – 5 Million
B – 11 Million
B – 17 Million
C – 22 Million
D – 34 Million

6. 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 Sgt 1st Class and Army Ranger
has to offer, including Leroy Arthur Petry is honored for
recognition for doing conspicuous gallantry
what no one wants to with the prestigious Medal of
do, and most would Honor by President Obama on
not try to do. July 12th, 2011

7. Integrated Post-Combat Care
Nationwide Community of Care Culturally sensitive care
for Returning Combat Veterans military culture: acknowledge service
and Their Families combat culture: acknowledge sacrifice
Collaborate with local VA facilities/
Vet Centers/community resources
Community
Providers Integration of care:
medical services
mental health services: screen for
co-morbid conditions, address
chronic pain, TBI, sleep
social services: family, job,
educational, financial

8. Veterans
Administration
VHA VBA
Veterans Health Veterans Benefits
Administration Administration
Provides medical exams and
healthcare Administers benefits
Cemeteries
Burials

9. VHA is a major contributor to the
nation’s healthcare system
Provides medical care to
6 million veterans
Healthcare
Healthcare Disaster
Workforce Relief
Research Homeless
9

10. LARGEST INTEGRATED HEALTH
CARE SYSTEM IN THE COUNTRY
153 Hospitals
951 Clinics (Hospital, Community-Based,
Independent and Mobile)
134
Community Living Centers
232 Readjustment Counseling Centers
VET CENTERS
50 Domiciliary Resident Rehabilitation Treatment Programs
10

11. VHA is a major contributor to
the nation’s healthcare
system
Provides medical care to
6 million veterans
Serves as the largest
single provider of
health professional Healthcare
training in the world
Healthcare Disaster
Workforce Relief
Research Homeless
11

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)
12

13. VHA is a major contributor to the
nation’s healthcare system
Provides medical care to
6 million veterans
Serves as the largest
single provider of
health professional Healthcare
training in the world
Healthcare Disaster
Workforce Relief
One of the largest and
most productive
research organizations
Research Homeless
in the country
13

14. VA Research Highlights
Radioimmunoassay
ASA in MI Prevention
ALLHAT
Implantable Cardiac Pacemaker
Genomic medicine
Nicotine Patch Shingles Vaccine Efficacy
Evidence Based PTSD RX
Deep Brain Stimulators in
Parkinson’s
First Liver Transplant
Lutein for Mac Degeneration Prosthetic Limbs
14

15. VHA is a major contributor to the
nation’s healthcare system
Provides medical care to
6 million veterans
Serves as the largest
single provider of
health professional Healthcare
training in the world
Healthcare Disaster
Workforce Relief
One of the largest and
Largest direct care
most productive
provider for
research organizations
Research Homeless homeless persons
in the country
in the country
15

16. 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. VHA is a major contributor to the
nation’s healthcare system
Provides medical care to
6 million veterans
Serves as the largest Principal Federal
single provider of asset for medical
health professional Healthcare assistance in large-
training in the world scale disasters
Healthcare Disaster
Workforce Relief
One of the largest and Largest direct care
most productive provider for
research organizations homeless persons
Research Homeless
in the country in the country
17

18. 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

19. WHO are our Veterans today and in the
future?
8.4 million are
enrolled in our
22,658,000 U.S. system 6 million patients
Veteran received VHA
Population (8% health care in 2010
female)
Over 662,000
admissions
annually The number of
73.0 million women Veterans
outpatient visits will double in the
The number of next 5 years.
Veterans 85 years
and older is more
than 1.3 million.

20. VHA Primary Care by Age & Gender
44%
8% Female 25%
1.4
1.2
Million patients
1.0
0.8 21% had encounter
in Mental Health
0.6
0.4
0.2
0.0
<25 25-34 35-44 45-54 55-64 65-74 75-84 85-up
Age
Female Male

21. What do all of these patients
have in common?
41 yo male accountant 27 yo female office
with obesity and DM worker with
PTSD, 24th week IUP
36 yo male nurse
with labile HTN
68 yo male social worker
CHF, hep C, depression
60 yo male
lawyer with HIV/AIDS
complications 82 y/o male with dementia,
recently widowed
42 yo female
shopkeeper 57 y/o female bus driver
with MS with breast cancer

22. They are all Veterans
But you won’t know unless you ask!
SOMALIA
IRAQ
AFGHANISTAN
VIETNAM
KOSOVO
WWII
GULF WAR I
KOREA

23. How will I know if someone is a Veteran?
What Do I don’t agree
Veterans with this war
Look Like? and can’t hide
those feelings!
What do I say if they were in combat?
They would
I should not
tell me if they ask,
wanted me it might
to know. upset them.

24. 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
24

25. • 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
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”

26. Tune in to Military Culture

27. Mission Driven:
To care for those who have borne the battle
and for their families and loved ones

28. CORE VALUES
Duty ▪ Honor ▪ Country

29. Cultural
Competency
What does it mean to be a Veteran?
ASK ▪ LISTEN ▪ LEARN

30. •
The Beginning of Lifelong
Training

31. Who wears these uniforms?
Coast
Guard
Army
Air Force
Navy Marines

32. Women Who Serve

33. History of Recent Conflicts
• World War II 1941-1945
• Korean War 1950-1953
• Vietnam 1961-1975
• Grenada 1983
• Panama 1989
• First Gulf War
1990-1991

34. 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/OND
2011-Present

35. Difference Between
CONFLICTS & STRESSORS
• Length of Conflict
• Threat
• Weapons
• Individual Protective
Equipment
• Types of Missions
• Environmental
Exposures
• Casualties

36. Positive Influences
in Combat & Deployments
• 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

37. 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 deployments
o Impact on family
o Post military plans/goals

38. 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.”

39. The environment of war

40. What are the health concerns
of OEF/OIF/OND veterans seen in the VA?
1,396,477 of the 2.25 million deployed are separated and eligible for VA care
53% have been seen in VA between FY02 and December 2011
54% are former active duty and 46% are reserve and national guard
• 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
40

41. Co-morbid Concerns in
Combat Veterans
Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009 JRR&D
Sample = 340 OEF/OIF outpatients at Boston VA
TBI/Pain
12.6%
10.3%
5.3%
PTSD, TBI, Pain
6.8% 16.5%
42.1%
Overall prevalence in
Polytrauma population:
Pain 81.5%
TBI 68.2% PTSD
PTSD 66.8% CLARK- 2009 2.9%

42. Post-Deployment Health Care Needs
Combat
Non- injury Marital/family
combat TBI financial
injury difficulties
Non-combat
illness Post-combat
Environmental Spiritual /
symptoms
exposure existential
illness struggles
Hearing loss C&P
tinnitus needs
Mental
health

43. Post-Deployment Integrated Care
Combat
Non- injury Marital/family
combat TBI financial
injury difficulties
Non-combat
illness Post-combat
Environmental Spiritual / symptoms
exposure existential
illness struggles
Hearing loss C&P
tinnitus needs
Mental
health

44. Clinical Pearls for Care of Combat Veterans
1. 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

45. 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 family
o 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

46. 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(1-2mg15mg 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

47. OEF/OIF/OND Program
• Outreach
• Transition
• Intake
• Triage
• Case Management
• Care Coordination
47

48. 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

49. Vet Center Video
• http://www.vetcenter.va.gov/media/confessions/con
fessions.asp
49

50. 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

51. Joining Forces
• 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.

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

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

54. Integrated Post-Combat Care
Physical Psychological
Veteran
Psychosocial

55. Integrated Post-Combat Care
Primary Care Mental Health
Veteran
Social Worker/
Case Manager

56. Integrated Post-Combat Care
Nationwide Community of Care Culturally sensitive care
for Returning Combat Veterans military culture: acknowledge service
and Their Families combat culture: acknowledge sacrifice
Collaborate with local VA facilities/
Vet Centers/community resources
Community
Providers Integration of care:
medical services
mental health services: screen for
co-morbid conditions, address
chronic pain, TBI, sleep
social services: family, job,
educational, financial

57. Clinical Pearls for Care of Combat Veterans
1. 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

58. 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 family
o 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

59. 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(1-2mg15mg 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

60. Presumptive Benefits
Certain categories of Veterans may have conditions
that are presumptively considered service connected
Agent Orange-exposed Veterans
 Any 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 Veterans
Former Prisoners Of War (POW)

61. 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

62. 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

63. Web-Based Applications
MilitaryKidsConnect.org
AfterDeployment.org SuicideOutreach.org

64. Mobile Applications

65. Breathe2Relax
Breathe2Relax 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
65
• Audio narration

66. PTSD Coach
T2 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
66

67. mTBI Co-occurring
Conditions 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
67

68. New Ways to Connect
Resources to Support Health Recovery

71. LISTEN, LEARN and LOCATE

73. 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/

74. Connecting: Doubts Video
http://youtu.be/rKzN2yI5DTU

75. It’s Not Your Father’s VA
Stephen Hunt MD, MPH
Lucile Burgo MD
VHA POST DEPLOYMENT
INTEGRATED CARE INITIATIVE