Statement of
Michael J. Kussman, MD
Deputy Under Secretary for Health
Department of Veterans’ Affairs
July 27, 2005
Mr. Chairman and Members of the Committee, I appreciate the opportunity
to appear before you today to discuss the Department of Veterans
Affairs’ (VA) Post Traumatic Stress Disorder (PTSD) programs, and our
capability of meeting the mental health and physical health needs of
veterans returning from Operation Enduring Freedom and Operation Iraqi
Freedom (OEF/OIF), in their seamless transition from Department of
Defense (DoD) to (VA) care.
VA is well positioned to provide health care to returning OIF and OEF
veterans. As the largest integrated health care organization in the
United States, we can meet returning veterans’ needs through nearly
1,300 health care facilities throughout the country, including 721
community-based outpatient clinics that provide health care access near
most veterans’ homes. We also have 207 Vet Centers, which are often the
first contact points for returning veterans seeking health care and
benefits near their homes.
Thankfully, the great majority of OEF/OIF veterans will not suffer
long-term consequences of their war zone experience, although many will
have some short-term reactions to events witnessed in the combat
theater. Of those who do develop mental and emotional problems, PTSD may
not be the only problem we must attend to. They may also have other
medical or psychological injuries. The July 2004 New England Journal of
Medicine article, “Combat Duty in Iraq and Afghanistan, Mental Health
Problems, and Barriers to Care” by Charles W. Hoge, M.D., et. al,
concluded that 17 percent of troops returning from Iraq met strict
screening criteria for major depression, generalized anxiety, or PTSD.
The development of PTSD symptoms in some veterans will be delayed. Not
all will come for care at the same time. Some may seek care outside of
VA. Still others, for a variety of reasons, including the stigma
associated with mental disorders, may not seek care at all.
I plan to speak to you today about: 1) the mental healthcare services
utilized to date by OIF/OEF veterans; 2) VA’s outreach to OIF/OEF
veterans to inform and educate them about the mental healthcare services
available to them; 3) portals of entry, screening for mental health
conditions, and referral patterns within VA; 4) mental healthcare
programs that already exist to support those reaching out for help; 5)
challenges that we face in terms of data sharing so that we might
identify potential candidates for mental healthcare services; 6) VA’s
planning for future mental health services; and 7) lessons we have
learned to help us be better prepared for the future mental healthcare
needs of all veterans, including the OIF/OEF population.
Use of VA Mental Health Services by OIF/OEF Veterans:
With DoD’s help, VA regularly compiles a roster of service members who
have separated after active duty in Iraq and Afghanistan theatres. VA
matched the roster with information on VA healthcare utilization and
found that VHA medical centers have treated almost 101,000 of the
393,000 OIF/OEF veterans separated from active service. The two most
common potential health problems of war veterans in this population to
date have been musculoskeletal ailments and dental problems.
Almost 24,000 patients have been diagnosed with potential mental health
disorders including adjustment reaction and PTSD. Over 14,000 OIF/OEF
veterans have sought VA care at both Vet Centers and VA medical centers
for issues associated with PTSD.
PTSD and adjustment reactions are not the only potential mental health
consequence of war. Other potential mental health conditions include
depressive disorder, acute reaction to stress (often a precursor of
PTSD) and nondependent abuse of drugs or alcohol dependence syndrome.
When considering the mental health consequences of war zone service, it
must be recognized that nearly every service member who is exposed to
the horrors of war comes away with some degree of emotional distress.
Some will have some short-term adjustment reactions, but the majority
will not suffer long-term consequences from their combat experience.
Outreach:
VA is engaged in a number of activities to inform veterans and their
families of the benefits and services available to them. VA’s
orientation towards returning service members from the Global War on
Terror (GWOT) incorporates a public health approach to care and is
guided by the principles of the President’s New Freedom Commission (PNFC)
on Mental Health. VA’s Mental Health Strategic Plan (MHSP) is based on
the principles of that Commission, including the principles of health
promotion and preventive care. The initiatives in the MHSP emphasize
patient and family education about good health care practices and
identify behaviors to avoid. VHA is working to lower the incidence of
long-term mental health problems in the OIF/OEF population through a
concentrated effort at early detection and intervention.
VA identifies new OIF and OEF veterans who have separated from the
military based on names and addresses provided by DoD. The Secretary of
Veterans Affairs mails new veterans a letter welcoming them home,
thanking them for their service to their country, and briefly explaining
which VA programs are available to them. This includes care for medical
and mental health problems that may be related to their combat service.
As of June 30, 2005, VA has mailed more than 357,000 letters to
discharged service members.
Outreach to returning members of the Reserves and National Guard is a
special concern for VA, and, in collaboration with DoD, emphasis on this
has expanded significantly. In FY 2003, VA briefings reached nearly
47,000 reserve and guard members. During FY 2004, VA briefed more than
88,000 reserve and guard members, and in FY 2005, VA has already reached
more than 68,000 reserve and guard members. In addition, both
Departments have developed a new brochure together, entitled “A Summary
of VA Benefits for National Guard and Reserve Personnel.” The brochure
summarizes the benefits available to these veterans upon their return to
civilian life. VA has distributed over a million copies of the brochure
through VA and DoD channels. It is also available online at a new “Iraqi
Freedom” link on VA’s Internet Website, along with a variety of other VA
brochures and health information.
A critical element of our outreach efforts are VA’s Readjustment
Counseling Service Centers (known as “Vet Centers“). Having served
almost 21,000 veteran returnees to date, the Vet Center program locates,
informs and professionally engages returning veterans and their family
members about VA benefits and services including readjustment needs and
the complete spectrum of VA services and benefits.
The Vet Center program’s capacity to provide outreach to veterans
returning from combat operations in OEF and OIF was augmented by VHA’s
Under Secretary for Health (USH) in February 2004. Targeted Vet Centers
hired and trained a cadre of approximately 50 new outreach workers from
the ranks of recently separated GWOT veterans. These positions are
located on or near active military out-processing stations, as well as
National Guard and Reserve facilities. Based on the success of the
initial GWOT veteran outreach program, the Under Secretary for Health
authorized the further hiring of 50 more GWOT veteran outreach workers.
The Vet Centers are now engaged in hiring 50 more GWOT veteran outreach
workers to welcome home and inform their colleagues returning from
Afghanistan and Iraq.
Veterans helping veterans has been a central feature of the Vet Center
program throughout its 25 years of service to homecoming war veterans.
Nothing can replace the immediate rapport generated by veterans with
similar military experiences. These first outreach encounters provide
the initial stage for healing and successful readjustment. With early
intervention, clinicians hope to prevent the more debilitating onset of
chronic PTSD and set the stage for a seamless transition to their home
community and into local VA care.
Portals of Entry, Screening, and Referrals for Specialized Care:
OIF/OEF returning service members seek out and enter VA care from a
variety of sources including referral from military treatment
facilities, Transition Assistant Program briefings, Vet Centers, and
home town community service providers.
When OEF/OIF veterans present to VA clinicians with mental, emotional or
behavioral complaints, they are assessed both for symptoms, functional
problems, and clinical needs. Treatment plans may include referral to a
mental health clinic or Vet Center.
It is important to note, that once within VA, every OEF/OIF veteran who
presents for care is screened for PTSD, depression, alcohol abuse and
infectious diseases endemic to South West Asia through a reminder that
“pops up” in the Consolidated Patient Record System. The clinician is
obliged to complete the items on this screen, thereby ensuring that the
veteran is assessed for these problems. In fact, the mental health items
are identical to those that are used for routine annual screening of all
veterans who are cared for by VA.
Programs:
VA has a variety of programs and settings in which mental health
services are provided. Through our VA medical centers, VA provides
comprehensive care for veterans with mental illness through a continuum
of services designed to meet the patients’ changing needs. The spectrum
of care provided includes acute inpatient settings, residential services
for those who require structured support prior to returning to the
community, as well as a variety of outpatient services. Outpatient care
options include mental health clinics; “partial hospitalization”
programs such as day hospitals and day treatment centers that offer care
3 - 5 days a week to avert the need for acute or extended inpatient
care; and intensive case management in the community. Long-term
inpatient or nursing home care is also available, if needed. VA’s
specialized mental health programs include programs designed to meet the
needs of patients with disorders such as schizophrenia, major
depression, PTSD, and addictive disorders. Specialized PTSD programs
exist in all VA’s 21 Veterans Integrated Service Networks (VISNs or
Networks), including outpatient, inpatient and residential care
programs. As of 2005, each VISN has a PTSD Coordinator who facilitates
PTSD services across the VISN and serves as liaison with the Mental
Health Strategic Health Care Group in VA Central Office.
A primary goal of the Returning Veterans Outreach, Education and Care (RVOEC)
program will be to promote awareness of health issues and health care
opportunities and the full spectrum of VA benefits. Thirty-seven RVOEC
programs were funded, targeting sites associated with large numbers of
returning service members. There is at least one in each VISN.
The Vet Center program is a special VHA program designed to provide
readjustment counseling to veterans exposed to the uniquely stressful
rigors of military service in a combat theater of operations. Providing
holistic services to veterans and family members is a core component of
VA’s community-based Vet Center program. The Vet Centers are a unique
complement to VA’s arsenal of PTSD programs. They combine professional
readjustment counseling for war trauma with family services, outreach
and community coordination of care. Since August 2003, those services
include bereavement counseling to surviving family members of Armed
Forces personnel who died while on active duty in service to their
country.
Data Sharing:
As VA began its efforts with DoD to seamlessly transition the most
severely injured veterans and service members, both healthcare systems
adapted quickly to use traditional manual processes to collect and share
data to ensure continuity. VA assigned social workers and benefits
counselors to eight major Military Treatment Facilities (MTFs). These VA
social workers and benefits counselors receive referrals from DoD social
work discharge planners and case managers on injured service members who
will be transitioning to VA.
VA benefits counselors and social workers also participate in the
military treatment team’s multidisciplinary rounds. During rounds, each
OEF/OIF veteran is discussed and his or her care reviewed. Through this
collaboration, VA benefit counselors and social workers ensure that
returning service members promptly receive benefits for which they are
eligible, as well as other information and counseling about other VA
benefits and services. At the time of discharge to VA, DoD provides
summary clinical information. In many cases, DoD also provides a copy of
the medical record for the most recent period of treatment. With this
information, VA social workers coordinate the transfer of the service
member to the appropriate VA health care facilities; enroll them into
the VA health care system; and initiate paperwork for compensation
claims and benefits.
As the war evolved, DoD began to share various national electronic data
files of administrative data on discharged service members. While this
information has been very useful to VA, the data is not as comprehensive
as VA would want to provide truly seamless clinical care.
In order to address these data sharing issues, VA is working
collaboratively with DoD to develop functionality that will support the
transfer of the full history of pre- and post-deployment health
assessment data on OEF, OIF and other deployed service members to VA
physicians and claims examiners. DoD is scheduled to begin sending
electronic copies of this data to a secure shared repository in the 4th
Quarter of FY05. Monthly updates of this data will continue to be sent
as additional deployed service members separate from military duty.
VA is presently working on enhancements, using the Federal Health
Information Exchange (FHIE) infrastructure and its own health
information record, that will permit authorized VA clinicians to view
these data on demand at all VA facilities when a recently discharged
combat or other veteran presents for care. VA anticipates completing
this work during the 1st Quarter of FY06. Although the current work is
focused on providing the pre and post deployment data for clinical care,
the Departments are actively exploring the feasibility of using these
data for epidemiological studies.
On June 21, 2005, VA and DoD signed a Memorandum of Understanding for
the purposes of defining data sharing between the Departments. This
agreement lays the foundation for VA to receive the list of service
members who enter the Physical Evaluation Board (PEB) process. Although
the seamless transition initiative was initially intended to support
service members who served in OEF/OIF, it is intended to become an
enduring process which will support all service members who, as a result
of injury or illness, enter the disability process leading to medical
separation or retirement.
The PEB list will identify those individuals who by virtue of their
service sustained an injury or developed an illness that precluded them
from continuing on active duty and resulted in medical separation or
retirement. The list will enable VA to contact these service members to
initiate benefit applications, disability compensation claims
processing, and transfer of their health care to VA Medical Centers
before they are discharged from the military. DoD is developing a policy
to govern the business rules of sharing this data, including applicable
data privacy and security protections. Once the policy is approved and
signed by both Departments, DoD will start sending the list to VA.
Access to these data will help ensure that any service member who was
seriously wounded or injured or has become seriously ill while in
defense of our country will have seamless access to the timely and
highest-quality services they need and deserve, regardless of where they
are in the transition process. VA looks forward to the receipt of these
data from DoD.
Planning for the Future:
VA has worked very hard to establish demand estimates for mental health
services for all veterans for strategic planning purposes. Current
utilization of VA mental health services is tracked as part of the
population based assessment of needs that is embodied in the CARES
process and is the driver for the clinical planning in the Mental Health
Strategic Plan (MHSP). Over the past several years, the population of
existing veterans receiving care for PTSD has increased by about 20,000
per year. Although the numbers of OEF/OIF returnees are relatively small
it is essential that the numbers of veterans be brought into the
actuarial planning model.
The VA Enrollee Health Care Projection Model forecasts demand for VA’s
inpatient and outpatient mental health and substance abuse services.
Over the past several years, VHA has worked with a group of mental
health experts to enhance the model methodology. An important
improvement was to develop individual models for those services that are
unique to VA, such as PTSD residential rehabilitation.
We have also incorporated “age cohorts” into the model. Age cohorts
allow us to adjust the model for the special mental health demand of
veteran enrollees as they age. For example, Vietnam-era veterans are
expected to have higher demand for mental health and substance abuse
services than World War II and Korean-era veterans as they age. In
addition, we have developed a methodology to model a consistent level of
access across the VA health care system. These enhanced projections
support the implementation of the VHA Mental Health Strategic Plan and
will enable VA to plan to meet enrollees’ need for mental health and
substance abuse services for the next twenty years. The mental health
workgroup is continuing its work to enhance the mental health model.
Lessons Learned:
As it relates to mental health care, VA has learned a number of lessons
in addressing the needs of recently discharged OIF/OEF service members.
One of these is the importance of the timely receipt of medical and
administrative data from DoD on separated or soon to be separated
service members. The PEB data will be invaluable in VA’s ability to
reach out to a high risk population. In addition, access to pre and post
deployment screening data for soon to be separated service members is
highly desirable.
The second lesson, and supporting the need for data, is the importance
of early intervention when problems, especially mental health problems,
arise -- whether this is while the person is on active duty or after
they are separated. At the March 2005 Joint VA/DoD Conference on Post
Deployment Mental Health, it was clearly acknowledged by VA and DoD
clinicians that early intervention is an essential step in limiting the
development of more severe and lasting psychopathology.
The third lesson is promoting approaches that minimize the stigma
associated with mental health. These approaches will empower more
service members to seek help. Combating the stigma attached to mental
disorders is one of the first goals of the VA’s Mental Health Strategic
Plan. The application of the public health approach to returning GWOT
veterans and the recovery and rehabilitation approach to the adjustment
problems of war is based on de-pathologizing these problems before they
harden into actual mental disorders.
Vet Centers have extensive experience working with veterans to overcome
negative attitudes and stigmas typical of combat veterans related to
accessing professional assistance. Community outreach and other
accommodations to improve access to care for veterans are essential to
veterans’ readjustment. This is true both from the standpoint of
ensuring services are provided in a timely manner for new eras of
veterans returning from combat and peace-keeping missions, as well as
from the standpoint of overcoming psychological and cultural barriers to
care. Vet Center counselors are especially effective in forging
alliances with local veterans through outreach contacts in the community
prior to initiating more formal individual or group counseling at the
Vet Center.
Conclusion:
The goal of VA’s public health approach is to decrease the incidence of
serious mental disorders. There is evidence from VA’s initial activities
in the field that these approaches are accepted both by clinicians and
the veterans they serve. We believe this approach may well decrease the
incidence of chronic mental disorders for veterans. It will require up
front resources which VA is putting in place, but will pay off in the
long run, in terms of decreasing human pain and suffering and increasing
the social and occupational function of veterans. For those who do
develop mental disorders, decreasing the stigma of receiving care by
teaching the public about the efficacy of evidence based treatment, can
increase the beneficial use of these services whose goal is the
restoration and preservation of optimal social and occupational
functioning.
In conclusion, VA will continue to monitor and address the mental health
needs of the OIF/OEF population, just as it does the general veteran
population, through progressive, state-of-the-art programs. VA is
approaching the mental health needs of returning veterans with an
orientation that is designed to promote an optimal level of social and
occupational function and participation in family and community life for
our veterans. We are prepared to provide state of the art evidence based
care to those coming to us for care, who through their service to our
nation, deserve nothing less.
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