Pain week hunt burgo 7.4.12
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  • Thank you for having me I have been a PCP at the Connecticut VA for 25 years and feel very privileged to have spent my career taking care of the men and women who have served our country. I would like to share with you some basic knowledge about the VA to help you take care of Veterans. We have been faulted by many for not sharing, but this has been changing as recent legislation permits VA more robust outreach tools such as public service announcements and sharing agreements for bidirectional information exchange. This of course is in recognition of the need for transparency and collaboration if we are going to provide Veterans with the best care.
  • Unfortunately War seems part of the human condition and inevitable in our world and we must as a nation be prepared to deal with the consequences  This reminds me of a few weeks ago when President Obama awarded the Medal of Honor, our nations highest honor for exemplary bravery reminding us how important it is that we recognize our service members and welcome them back as communities who care. The medal was awarded to an army ranger with 8 deployments Sergeant First Class Leroy Petry. He earned the award when his team came under insurgent attack during a raid in Afghanistan in 2008. A fighter lobbed a grenade at his men, but SFC Petry grabbed it and tossed it away without hesitation. He lost a hand and took shrapnel in the process, but saved the lives of his men. As the saying goes, he showed “conspicuous gallantry above and beyond the call of duty.” risking his life through great individual sacrifice enabling his team to complete their mission. If we ask our sons and daughters, brothers and sisters 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.
  • So I’d like to tell you a little bit about the Veterans Administration. We are a cabinet level department led by Secretary Shinseki, who himself served, There are 3 branches the Veteran’s Health Administration which provides medical exams and healthcare, the Veterans Benefit administration which adjudicates and provides benefits and Cemeteries for burial.
  • We are the largest integrated healthcare system in the country providing medical care to over 6 million Veterans  
  •  We are the largest single provider of health professional training in the world
  • We are one of the largest and most productive research organizations in the country
  • the highlights include the first implantable Cardiac pacemaker, the first liver transplant, amazing prosthetic limbs, development of radioimmunoassay, deep brain stimulatiors for Parkinson's, the nicotine patch, the important ALLHAT study , and use of ASA for MI prevention in unstable angina
  • We are the largest direct care provider for homeless persons in the country
  • As greater than 30% of the nation’s homeless are Veterans Secretary Shinseki has a decisive five year plan to end veteran homelessness so all veterans who are homeless or at risk have easy access to programs and services. 
  • We are the principal federal asset for medical assistance in large scale disasters.
  • In Hurricane Katrina 18 VA Federal coordinating Centers were activated I also remember Connecticut being activated for 9/11 but of course there were so few injured that we were not used. VA was recognized for doing a good job in the evacuationand I would also like to point out the value our electronic medical record during Katrina which permitted instant access to comprehensive electronic health records of all the veterans evacuated to other VA facilities 
  • Let’s look at some typical primary care patients. A 41 -year-old male accountant with obesity and diabetes 27 -year-old female office worker with PTSD , 24 weeks pregnant, a 61 -year-old male social worker with congestive heart failure and depression and 82 -year-old male with dementia recently widowed and a 60 year-old male lawyer with HIV AIDS complications.  What do all these patients have in common?
  • They are all Veterans but you won't know unless you ask
  • They may be new to your practice They may not think it relevant to their healthcareThey may prefer to forget that time in their livesThey may be very proudThey may be reluctant to share their storiesThey may think others need help more We won’t understand how their service has impacted their lives and their health unless we ask!It means a lot to me that you are a Veteran. I appreciate your service and your sacrifice. I want to hear your story
  • This is the slide to talk about ranks and the individual story thru his uniform Our experience at MHS
  • Slide # 15Although integrated in 1976, women have officially served since WWI and much more throughout our history unofficially. With the ever increasing numbers of women serving in the military, the impact on military culture as a whole has been transformational. The AF has highest % (19%)with only one career field not available to women. The Navy just opened up submarine service to women. 15-16% of deployers to OEF/OIF have been women.Women in the military will tell you that they just want to be able to do our jobs.There are many resources on the issues of women in the military and I would highly encourage you to become more familiar with all the resources.
  • 14 M went to war in WWII. 1 M suffered combat stress. No programs. Came home went back to work. Greatest generation.Korean War: forgotten war. Many vets were reservists who were “called up.”Vietnam: elusive political objectives; poor military strategy; national shame. These vets can never hear “thank you” enough.Almost forgotten: Grenada, Panama.First Gulf War: new generation; lots of technology; more roles for women-first open use of women in combat.World War II (1941-1945)14 million with 400,000 deaths and 670,000 woundedKorean War (1950-1953)1.7 million with 36,000 deaths and 92,000 injuredVietnam (1961-1975)*2.5 million with 58,000 deaths and 303,000 injured*Military advisors 1950-1961\\\\\\
  • Also almost forgotten: Somalia, Bosnia, Kosovo.Today’s vets: Multiple deployments. Different environment with each deployment. More technology, PPE, awareness of exposures etc. 16% of in theater military are women in varying roles including combat on a regular basis. Similarities to Vietnam: political objective lacking after the fact, insurgency likened to Viet Cong; nation weary of war--no clear exit strategy.
  • Length of Conflicts: Vietnam 14 yrs. OEF 9 yrs OIF 7 yrsWeapons: Artillery use, Napalm/jungle warfare, IEDs/VBIEDs#Deaths vs. Injuries with Long Term DisabilitySoldiers with prosthetics return to battlefield.WWII: Total casualties -1,076,245 (405,399 KIA & 670,846 WIA) Ratio was 1.7:1 (WIA to KIA)Korea: Total casualties -128,650 (36,516 KIA & 92,134 WIA) Ratio 2.5:1Vietnam: Total casualties – 361,904 (58,260 KIA & 303,644 WIA) Ratio 5.2:1OEF & OIF: Total 41,661 – ( 5,684 KIA & 35,977 WIA) Ratio 6.3:1Conditions of Today’s Battlefield:Homeland Attack (similar to Pearl Harbor)Asymmetrical threatGuerilla War (similar to Vietnam)No safe havensResourceful enemy with much improvisation and technology access
  • Not all bad news.Dedication, fortitude, inner strength emerges.
  • Bio psychosocial Approach
  • Clinical PearlsTo finish I’d like to give you a few clinical pearls on the care of service members back from combat.Most Importantly express gratitude for their service and sacrifice. This can have a profound effect. We are actually seeing a lot of new Vietnam Veterans coming in to get connected for Agent Orange benefits and many of them are being thanked for their service and sacrifice for the first time. These can be very emotional for them and greatly appreciated Take a military history. Tell me about your 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 exposed to blasts? Understand the barriers to care and the stigma of mental health and being labeled also the competing demands of family, work and school.Psychological symptoms can be profound barriers asPTSD is often characterized by significant avoidance, depression by low motivation, substance use disorders by denial and poor adherence and mild TBI by poor concentration and memory.  
  • With Mild to Moderate readjustment difficulties Provide close follow up and involve families. Monitor for progression assessing for sleep disturbance and substance abuse and ask them how things are going in their relationships, their work and school. Focus on their functioning.There are VA POST DEPLOYMENT PROGRAM MANAGERS at every facility who can help coordinate community and VA services ----- Meeting Notes (3/9/12 10:10) -----Know your resources
  • Musculoskeletal pain is by far the most common presenting complaint. Keep in mind that comorbid mental health conditions lower pain thresholds and effective treatment strategies must treat both. Reserve opiates for select/refractory cases given the high risk of substance abuse/misuse. Use an interdisciplinary approachHelping manage disrupted sleep patterns can significantly improve their overall function When they first return getting back on a normal sleep cycle is very difficult. Provide instruction in sleep hygiene. If they are bothered by distressing nightmares with nocturnal awakenings prasozin starting at a dose of 1-2 mg and titrating up to 15 mg at bedtime can be helpful.If you suspect they have Post traumatic Stress provide psycho education, coping skills The key here is to engage them and destigmatize mental healthcare so that when they are ready they can be referred for evidence based therapy. Primary care providers can start treatment and SSRI’s can be extremely beneficial in symptom management but benzodiazepines should be avoided
  • There are some important benefits for the newest returnees but they need to enrollThey have five years cost free comprehensive health care for preventive benefits and any condition related to their service and they can continue care after the initial five-year period for service connected conditions. They have a one time dental benefit within 180 days of separation.There’s a returning service member program in every VA facility that is available for assistance, liaison and care coordination The Vet centers provide Veterans and families with free readjustment counseling and outreach. The Vet Centers were created in 1979 to help Vietnam War veterans readjust to society, and now assist veterans of Iraq and Afghanistan and all other wars. Located throughout the country, the centers are small, storefront operations with a staff of four to five people, each designed to provide a safe environment for service members who have been traumatized by combat. Today, there are 300 Vet Centersand 50 Mobile Vet Centers Four of these highly agile and adaptable mobile centers were used in the aftermath of the mass shooting at Fort Hood in November 2009 to provide counseling to more than 8,000 active duty military personnel and their families. Lets hear the Veterans themselves tell us about the Vet Centers
  • These slides actually have live links which the PDF in the syllabus doesn’t and I will be happy to send them if you email me. Other resources to support health recovery are the new post-9/11 bill which pays benefits in an approved education or training program There are Veterans employment coordination services with Veteran preference for federal jobs. The new caregiver bill will provide financial support and health insurance to caregivers of veterans. We have life insurance, home loans and vocational rehab and pregnancy services for our ever-increasing number of women.
  • Clinical PearlsTo finish I’d like to give you a few clinical pearls on the care of service members back from combat.Most Importantly express gratitude for their service and sacrifice. This can have a profound effect. We are actually seeing a lot of new Vietnam Veterans coming in to get connected for Agent Orange benefits and many of them are being thanked for their service and sacrifice for the first time. These can be very emotional for them and greatly appreciated Take a military history. Tell me about your 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 exposed to blasts? Understand the barriers to care and the stigma of mental health and being labeled also the competing demands of family, work and school.Psychological symptoms can be profound barriers asPTSD is often characterized by significant avoidance, depression by low motivation, substance use disorders by denial and poor adherence and mild TBI by poor concentration and memory.  
  • With Mild to Moderate readjustment difficulties Provide close follow up and involve families. Monitor for progression assessing for sleep disturbance and substance abuse and ask them how things are going in their relationships, their work and school. Focus on their functioning.There are VA POST DEPLOYMENT PROGRAM MANAGERS at every facility who can help coordinate community and VA services ----- Meeting Notes (3/9/12 10:10) -----Know your resources
  • Musculoskeletal pain is by far the most common presenting complaint. Keep in mind that comorbid mental health conditions lower pain thresholds and effective treatment strategies must treat both. Reserve opiates for select/refractory cases given the high risk of substance abuse/misuse. Use an interdisciplinary approachHelping manage disrupted sleep patterns can significantly improve their overall function When they first return getting back on a normal sleep cycle is very difficult. Provide instruction in sleep hygiene. If they are bothered by distressing nightmares with nocturnal awakenings prasozin starting at a dose of 1-2 mg and titrating up to 15 mg at bedtime can be helpful.If you suspect they have Post traumatic Stress provide psycho education, coping skills The key here is to engage them and destigmatize mental healthcare so that when they are ready they can be referred for evidence based therapy. Primary care providers can start treatment and SSRI’s can be extremely beneficial in symptom management but benzodiazepines should be avoided
  • Care provided at the VA is not all or nothing.50-70% of all Veterans are co managed with the private sector especially in more urban areas . I have partnered successfully with the community providers for years and not just as a pharmacy. We stay connected through sharing of information and develop a coordinated care plan that best meets the Veterans needs Let me point out that Veterans who are service connected for a condition pay nothing for a visit to me Otherwise there is a $15 co pay for primary care and a $50 copay for specialty care if their income falls out above our means testing. They would then also pay $9 a month for medications. Actually our PCP’s are spending a lot of time writing scripts for Target or WalMart with their 3 month $10 generic program which I am sure you are as well
  • These slides actually have live links which the PDF in the syllabus doesn’t and I will be happy to send them if you email me. Other resources to support health recovery are the new post-9/11 bill which pays benefits in an approved education or training program There are Veterans employment coordination services with Veteran preference for federal jobs. The new caregiver bill will provide financial support and health insurance to caregivers of veterans. We have life insurance, home loans and vocational rehab and pregnancy services for our ever-increasing number of women.new Post 9/11 GI BillVeterans Employment Coordination ServiceVA Caregiver Support ServicesLife Insurance , Home Loans, Survivor Benefits, Vocational Rehabilitation Homeless ServicesProsthetic and Sensory AidsPregnancy services
  • Interactive Web sites connection to a wealth of imformation for both Veterans and providers
  • New program to engage Veterans
  • Web resources These are live links so if you would like the slide set please email myself of Dr Hunt. I’d like to point out an important resource to help you identify all of the services and resources at the state and local level. The National Resources Directory their home page is a map And also the VA Returning Service member link   

Pain week hunt burgo 7.4.12 Pain week hunt burgo 7.4.12 Presentation Transcript

  • It’s Not Your Father’s VA Stephen Hunt MD, MPH Lucile Burgo MD 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 therecurrently in the United States?
  • How many veterans are therecurrently in the United States? A – 5 Million B – 11 Million B – 17 Million C – 22 Million D – 34 Million
  • MEDAL of HONORIf we ask these youngmen and women torisk life and limb in theservice of our countrywe must be preparedto serve them. Theyare the heroes ofAmerica. They deservethe best our society Sgt 1st Class and Army Rangerhas to offer, including Leroy Arthur Petry is honored forrecognition for doing conspicuous gallantrywhat no one wants to with the prestigious Medal ofdo, and most would Honor by President Obama onnot try to do. July 12th, 2011
  • Integrated Post-Combat Care Nationwide Community of Care Culturally sensitive care for Returning Combat Veterans military culture: acknowledge serviceand 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
  • Veterans Administration VHA VBA Veterans Health Veterans Benefits Administration AdministrationProvides medical exams and healthcare Administers benefits Cemeteries Burials
  • VHA is a major contributor to the nation’s healthcare system Provides medical care to 6 million veterans Healthcare Healthcare Disaster Workforce Relief Research Homeless9
  • 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 Programs10
  • 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 Homeless11
  • 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
  • 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 country13
  • 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 TransplantLutein for Mac Degeneration Prosthetic Limbs 14
  • 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 country15
  • 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
  • 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 country17
  • Disaster Assistance Hurricane Katrina (National Response Plan)18 VA Federal Coordinating Centers were activatedMobilized $1.3 million in critical pharmaceuticals and medicalsuppliesVA deployed mental health professionals and provided space fora 250 bed medical shelter at the VA in Alexandria, LouisianaVA employees evacuated 166 patients before the storm hitThe VA electronic health record supported continuity ofcomprehensive care for evacuated Veterans 18
  • WHO are our Veterans today and in the future? 8.4 million are enrolled in our22,658,000 U.S. system 6 million patients Veteran received VHAPopulation (8% health care in 2010 female) Over 662,000 admissions annually The number of 73.0 million women Veteransoutpatient visits will double in the The number of next 5 years. Veterans 85 years and older is more than 1.3 million.
  • VHA Primary Care by Age & Gender 44% 8% Female 25% 1.4 1.2Million 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
  • 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 IUP36 yo male nursewith 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
  • They are all Veterans But you won’t know unless you ask! SOMALIA IRAQAFGHANISTAN VIETNAM KOSOVO WWII GULF WAR I KOREA
  • 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 nottell me if they ask,wanted me it mightto know. upset them.
  • 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
  • • 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 moreWe won’t understand how their service hasimpacted their lives and their health unless we ask!“I appreciate your service and your sacrifice. I want to hear your story”
  • Tune in to Military Culture
  • Mission Driven:To care for those who have borne the battle and for their families and loved ones
  • CORE VALUESDuty ▪ Honor ▪ Country
  • Cultural CompetencyWhat does it mean to be a Veteran? ASK ▪ LISTEN ▪ LEARN
  • •The Beginning of Lifelong Training
  • Who wears these uniforms? Coast Guard Army Air ForceNavy Marines
  • Women Who Serve
  • 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
  • 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
  • Difference Between CONFLICTS & STRESSORS• Length of Conflict• Threat• Weapons• Individual Protective Equipment• Types of Missions• Environmental Exposures• Casualties
  • 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
  • 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
  • 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? 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 201140
  • 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 inPolytrauma population:Pain 81.5%TBI 68.2% PTSDPTSD 66.8% CLARK- 2009 2.9%
  • 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
  • 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
  • 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 sacrifice3. 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 Veterans4. Mild to moderate readjustment difficulties • Monitor for progression • Assess for sleep disturbance, • Screen for substance abuse • Ask about relationship/work/school issueso Close follow-up, involve familyo Focus on function • Ask how they are doing • Ask how are their relationships, their job, schoolo VA Post Deployment Program Managers can help with community and VA coordination of services
  • Clinical Pearls for Care of Combat Veterans5. 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 strategies6. Sleep • Sleep hygiene • prazosin for nightmares(1-2mg15mg qhs); • consider stepped approach Benadryl trazodone ambien7. 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
  • Vet Center Video• http://www.vetcenter.va.gov/media/confessions/con fessions.asp 49
  • 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• 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.
  • RECENT ARTICLEShttp://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 CarePrimary Care Mental Health Veteran Social Worker/ Case Manager
  • Integrated Post-Combat Care Nationwide Community of Care Culturally sensitive care for Returning Combat Veterans military culture: acknowledge serviceand 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
  • 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 sacrifice3. 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 Veterans4. Mild to moderate readjustment difficulties • Monitor for progression • Assess for sleep disturbance, • Screen for substance abuse • Ask about relationship/work/school issueso Close follow-up, involve familyo Focus on function • Ask how they are doing • Ask how are their relationships, their job, schoolo VA Post Deployment Program Managers can help with community and VA coordination of services
  • Clinical Pearls for Care of Combat Veterans5. 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 strategies6. Sleep • Sleep hygiene • prazosin for nightmares(1-2mg15mg qhs); • consider stepped approach Benadryl trazodone ambien7. 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 conditionsthat are presumptively considered service connectedAgent Orange-exposed Veterans  Any Vietnam Veteran who served in country is now considered exposed to Agent OrangeGulf War Veterans with undiagnosed or unexplained chronic illnessesIonizing radiation-exposed VeteransFormer Prisoners Of War (POW)
  • Agent Orange Presumptives Type 2 diabetes mellitus Ischemic heart disease Prostate cancer Hodgkins 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 MilitaryKidsConnect.orgAfterDeployment.org SuicideOutreach.org
  • Mobile Applications
  • Breathe2RelaxBreathe2Relax is a portable stressmanagement tool utilizing hands-ondiaphragmatic breathing exercise.Breathe2Relax uses state-of-the-artgraphics, animation, narration, and videosto deliver a sophisticated, immersiveexperience for the user.Features:• Initial setup guide to assist with tailoringapplication• Customizable backgrounds and music• Immersive tutorial videos• Body scanner to display effects of stress• Graphing to track effectiveness 65• Audio narration
  • PTSD CoachT2 collaborated with the VAs NationalCenter for PTSD to develop this app toassist Veterans and Active Duty personnel(and civilians) who are experiencingsymptoms of PTSD.It is intended to be used as an adjunct topsychological treatment but can alsoserve 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
  • mTBI Co-occurring Conditions ToolkitFeatures:• Guidance to primary careproviders on the assessmentand management of patientssynthesizes information fromthe following VA/DoD CPGS:mTBI, PTSD, depression,chronic opioid therapy andsubstance use disorder 67
  • 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 Stephen Hunt MD, MPH Lucile Burgo MD VHA POST DEPLOYMENT INTEGRATED CARE INITIATIVE