Rural Community Providers
and Veteran-Centered Care:
Working with VA’s Rural
Health Program
Harold Kudler, M.D.
Associate ...
What the Data Tells Us About
Our National Capacity to
Manage Deployment-Related
Mental Health Issues
• Of 22.2 million liv...
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...
Mental Health among
OEF/OIF/OND Veterans
• Possible mental health problems reported among
54% (486,015) of the 899,752 eli...
Our Focus: Deployment MH
Chronic Pain
TBI

Depression

MST

PTSD

Job

Homeless

Family

Grief

SUD
The Rural Dimension
• Rural Veterans
• 41% of all VA enrollees
• 39% of enrolled OEF/OIF/OND
Veterans
• 53% of Veterans in...
Beyond the DoD/VA Continuum
• Ideally all deployment-related Mental
Health problems would be picked up
somewhere within th...
Comparison to the National Vietnam
Veterans Readjustment Study
• Perhaps we should only be concerned
about those who choos...
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 ...
Serving Those Who Have Served:
Educational Needs of Health Care
Providers Working with Military
Members, Veterans, and the...
Participants
• 97.6% participation rate among 327 providers
who opened link
• Two-thirds were mental health professionals
...
Experience with Military/Veterans:
Military Cultural Competence
• Only one out of six (16%) providers had ever
served in t...
Key Findings of Serving
Those Who Have Served
• 56% of community providers don’t routinely
ask their patients about being ...
Disparities in Knowledge and Confidence
Among Community Providers:
Rural Matters!
• Rural Providers were significantly mor...
Disparities in Knowledge and Confidence
Among Community Providers:
Rural Matters!
• Rural Providers were significantly mor...
Needed:
On behalf of Service Members, Veterans
and their families:

Military and Veteran friendly
principles and practices...
Treating the Invisible Wounds of War
www.aheconnect.com/citizensoldier
• Free, accredited on-line trainings:
•
•
•
•
•

Mi...
• Searchable Provider Database at
www.WarWithin.org
• 1,500+ providers nationally
• 1,200+ providers in NC
• -- 96 of 100 ...
Keys to Building Military-Friendly
Practices & Health Systems
1. Ask each patient “Have you or someone close to you
served...
Keys to Building Military-Friendly
Practices and Health Systems
4. Connect providers with support on military medical
issu...
Draft Version of the First 4 Questions from the
VA Office of Academic Affiliations Military Health
History Pocket Cards
(h...
Key VA Websites for
Community Providers
• http://www.mentalhealth.va.gov/
communityproviders
• New from VA Office of Menta...
29

Painting a Moving Train
The Big Blue Button

30
Health on the Homefront:
Outreach to Rural Communities

VISN 6 Rural Health Program
Improving access and quality of care f...
Health on the Homefront:
Outreach to Rural Communities

Veteran-Centered Rural Health
• Leverage collaboration with the Vi...
Health on the Homefront:
Outreach to Rural Communities

OUR VISION
Within 3 years, VISN 6, in partnership with the Virgini...
The Goal
There will be
No Wrong Door
to which ANY Service Member,
Veteran or family member can come
for the right help
Wit...
QUESTIONS?
Connecting withveterans
Connecting withveterans
Connecting withveterans
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Connecting withveterans

  1. 1. 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
  2. 2. 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
  3. 3. 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/oefoifo nd/health-care-utilization/index.asp
  4. 4. 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) Depressive Disorder Affective Psychoses Neurotic Disorders: Alcohol Dependence: Nondependent Abuse of Drugs: Tobacco Use Disorder 261,998 205,221 123,772 181,892 59,081 42,592 128,792
  5. 5. Our Focus: Deployment MH Chronic Pain TBI Depression MST PTSD Job Homeless Family Grief SUD
  6. 6. 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
  7. 7. 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%?
  8. 8. 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
  9. 9. 92535 AD Members
  10. 10. 208,657 Dependents
  11. 11. 24, 037 RC Members
  12. 12. 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 deploymentrelated 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?
  13. 13. 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., & CornelisonGrant, V. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research & Treatment Center, 2011
  14. 14. 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
  15. 15. 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
  16. 16. 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”
  17. 17. 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
  18. 18. 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
  19. 19. Needed: On behalf of Service Members, Veterans and their families: Military and Veteran friendly principles and practices as part of a public health intervention
  20. 20. 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
  21. 21. • 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
  22. 22. 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
  23. 23. 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
  24. 24. 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 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?” 27
  25. 25. 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
  26. 26. 29 Painting a Moving Train
  27. 27. The Big Blue Button 30
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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!
  32. 32. QUESTIONS?
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