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. 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. 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. 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. Our Focus: Deployment MH
Chronic Pain
TBI
Depression
MST
PTSD
Job
Homeless
Family
Grief
SUD
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. 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. 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
14. 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?
15. 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
16. 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
17. 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
18. 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”
19. 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
20. 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
21. Needed:
On behalf of Service Members, Veterans
and their families:
Military and Veteran friendly
principles and practices as part of a
public health intervention
22. 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
23. • 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
24.
25. 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
26. 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
27. 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
28. 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
31. 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
32. 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
33. 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
34. 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!
