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B UILDING C OMMUNITIES OF C ARE : P UBLIC H EALTH P ERSPECTIVES AND C LINICAL P RACTICES IN S UPPORT OF M ILITARY C HILDREN AND T HEIR F AMILIES Harold.

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Presentation on theme: "B UILDING C OMMUNITIES OF C ARE : P UBLIC H EALTH P ERSPECTIVES AND C LINICAL P RACTICES IN S UPPORT OF M ILITARY C HILDREN AND T HEIR F AMILIES Harold."— Presentation transcript:

1 B UILDING C OMMUNITIES OF C ARE : P UBLIC H EALTH P ERSPECTIVES AND C LINICAL P RACTICES IN S UPPORT OF M ILITARY C HILDREN AND T HEIR F AMILIES Harold Kudler, MD. Associate Director, VA Mid-Atlantic Mental Illness Research, Education and Clinical Center and Duke University Durham, NC Rebecca I. Porter, PhD. Commander, Dunham United States Army Health Clinic Carlisle Barracks, PA

2 A GENDA Defining Communities of Care History of a Public Health Perspective Building Communities of Care for Military Children Community of Care Domains Programs that contribute to Communities of Care Coordination and Recommendations Across states Throughout the Nation For clinical, educational, and governmental impact

3 P EDIATRICIAN -T URNED -C HILD P SYCHOANALYST D.W. W INNICOTT O NCE S AID : T HERE IS NO SUCH THING AS A B ABY No child exists in isolation Military children develop through their relations with their military parents, other family members, caretakers, schools, communities, and the culture and operational tempo of the armed forces Thats what makes them military children

4 T HINKING P RESENT AND F UTURE DoD estimates that 57 percent of active duty troops serving in 2011 were the children of current or former active-duty or reserve service members To understand and promote the growth and health of military children, for their sake and for the sake of our nation, we must consider interactions that extend across families, communities, culture and time How does a nation develop communities of care that maximize resilience and minimize the health risks that military children and their families face ?

5 D EFINING C OMMUNITIES OF C ARE We define Communities of Care as complex systems that work across individual, parent/child, family, community, military, national and even international levels of organization to promote the health and development of military children

6 A H ISTORICAL P RECEDENT Military medical history demonstrated long ago that merging clinical and public health approaches can effectively help service members cope with the stress of deployment An outstanding example is the work of Dr. Thomas Salmon who served as chief consultant in psychiatry for General Pershings American Expeditionary Force during World War I

7 A L ESSON FROM W ORLD W AR I European military medical experts approached shell shock through a clinical model Soldiers stayed in the trenches until they developed all its signs and symptoms

8 A H EALTH S URVEILLANCE S TRATEGY A LIGNED WITH M ILITARY C ULTURE Attention and prompt action were instrumental to helping their buddies, helping their units and accomplishing their mission Military culture sees the health and success of the individual as inseparable from the health and success of the group: fertile ground for merging clinical and public health models of care

9 A S E ASY AS PIE Salmons doctrine of proximity, immediacy and high expectancy of success came to be known as the PIE model and remains a central principle of combat medicine today Combat Stress Control Teams across Iraq and Afghanistan have a 97 percent return-to-duty rate

10 B UILDING C OMMUNITIES OF C ARE FOR M ILITARY C HILDREN To apply Salmons principles to military children, we must first determine where their front lines are, identify the clinical and public health supports available to them, and apply a few basic tenets: All warfighters and all of their family members (including children) face difficult readjustments in the course of the deployment cycle Population-based approach is less about diagnosing an individual patient than about helping individuals, families, military units, and entire communities retain or regain a healthy balance despite the stress of deployment In the life of the family and the child, each developmental step builds on the relative success of previous steps

11 D YNAMIC P RINCIPLES IN W ORKING WITH M ILITARY C HILDREN AND THEIR F AMILIES Military parents resilience and vulnerability affects the resilience and vulnerability of their children Clinical experience suggests that children may be the most sensitive barometers of their family's adaptation Each family brings its own capacities and liabilities to the coping process, and each has successive opportunities to adapt over the course of the deployment cycle and in the years after

12 G UARD AND R ESERVE C HILDREN F ACE U NIQUE C HALLENGES Usually live far from military bases, treatment facilities or TRICARE providers Often strangers to the institutions of military life Many of these families did not think of themselves as military until plunged into the deployment cycle of our recent wars Less likely to have the steady companionship of other military children or reliable access to military child or family programs

13 T HE D OMAINS OF C OMMUNITIES OF C ARE Communities of care improve access to information and support through concerted action across clinical and public health domains Successful communities of care require innovative: Policy Practice

14 T HE S HIFT TO TRICARE The accelerated operational tempo in Afghanistan and Iraq drove a shift of military children out of care in military facilities and into civilian practices under TRICARE Unfortunately, TRICARE doesnt mandate basic training for providers so there is no guarantee that these providers understand military culture or deployment stress or their effects on military children Nor is there a guarantee that enough pediatricians, child mental health professionals or family therapists will be available to meet the needs of military children wherever they reside Guard and Reserve members, whose TRICARE benefits may be limited to the period immediately before, during, and after deployment, also face the difficult decision of whether to change pediatricians if their usual provider doesnt accept TRICARE

15 A RE C OMMUNITY P ROVIDERS P REPARED ? A recent survey of community providers (mental health and primary care combined) found that 56 percent dont routinely ask patients about military service or military family status http://www.mirecc.va.gov/docs/visn6/Serving_Those_Who_Have_S erved.pdf http://www.mirecc.va.gov/docs/visn6/Serving_Those_Who_Have_S erved.pdf Few had served in the military or trained in DoD or VA health systems Only 29 percent of community providers felt that they knew how to refer a veteran to VA care How can we assist community providers and advocate for military families?

16 E NVISIONING C OMMUNITIES OF C ARE DoD has tremendous capacity to support service members and their children through clinical and family services but there are limits … Community response must be flexible enough to track military families and their children as they change over time Military children dont wear uniforms but they should not go unrecognized and unsupported in their communities

17 O BSTACLES TO B UILDING C OMMUNITIES OF C ARE Health-care providers are trained focus on discrete diseases but communities of care require a broader perspective Many issues can affect families and children, creating a wide array of clinical and nonclinical needs

18 PTSD AND O THER D EPLOYMENT H EALTH P ROBLEMS C OEXIST W ITH AND ARE S TRONGLY A FFECTED BY N ON -C LINICAL I SSUES One of the most important predictors of whether combat veterans develop PTSD is their level of perceived social support from their families Difficult economic times are likely to exacerbate their PTSD, depression, substance abuse, chronic pain or other health problems PTSD or TBI may contribute to homelessness for veterans and their families Even the best clinical practice guidelines for deployment health problems need to incorporate public health perspectives

19 T HE BEST ARENA FOR INTERVENTION IS OFTEN THE COMMUNITY RATHER THAN THE CLINIC BUT HOW DO WE ENSURE THAT THERE IS NO WRONG DOOR TO WHICH SERVICE MEMBERS AND THEIR FAMILIES CAN TURN FOR THE RIGHT HELP ?

20 M ILITARY P ROGRAMS THAT S UPPORT C OMMUNITIES OF C ARE Family Readiness Groups (FRGs) connect families with their service members unit and with one another The FRG is the commanders tool Online virtual FRGs promote community support and continuity for geographically dispersed units

21 M ORE M ILITARY P ROGRAMS Military OneSource RealWarriors.Net AfterDeployment.Org, offers links to information, support and clinical resources

22 S TILL M ORE M ILITARY P ROGRAMS The Office of Deputy Assistant Secretary of Defense of Military Community and Family Programs coordinates Quality of Life Programs The Defense Centers of Excellence (DCoE) for Psychological Health and TBI Military Kids Connect

23 F AMILIES O VERCOMING U NDER S TRESS (FOCUS) UCLA and the Harvard School of Medicine collaboration A preventive intervention that teaches children and families to cope with difficulties The Navys Bureau of Medicine and Surgery adopted FOCUS through a contract with UCLA in 2008

24 FOCUS AS A B UILDING B LOCK OF C OMMUNITIES OF C ARE Detect stress early and effectively promote family and community resilience FOCUS uses the same principles in civilian communities (sometimes through online resources) FOCUS is scalable and portable, and can be tailored

25 N ATIONAL G UARD P ROGRAMS NG Family Assistance Centers open to all military families Operation: Military Kids (OMK), a collaboration with communities to support National Guard and Reserve children affected by deployment

26 M ILITARY P ARTNERSHIPS 4-H Clubs, a program of the US Department of Agriculture, partners with Army, Air Force, and Navy to support military children Boy Scouts of America serves 19,750 military children annually on bases around the world

27 T HE N ATIONAL R ESOURCE D IRECTORY Joint effort of Departments of Defense, Veterans Affairs and Labor to connects wounded warriors, service members, veterans, and their families and caregivers with helpful programs and services through a virtual community NRDs greatest weakness derives from its vast ambition Practical solution modeled by WarWithin.org, a demonstration project of the Citizen Soldier Support Program WarWithin.org – effective model of how to develop and maintain state-by-state content make the National Resource Directory more timely, accurate and useful

28 C IVILIAN R ESPONSES THAT S UPPORT C OMMUNITIES OF C ARE The National Military Family Association (NMFA) and the Military Child Education Coalition (MCEC): excellent examples of civilian organizations that effectively mobilize civilian communities Zero to Three : develops high quality training and education to meet the needs of military families and infants Give an Hour : organizes health professionals and others who volunteer free services to meet the mental health needs of service members and their families – including Community Blueprint

29 T HE M ILITARY C HILD E DUCATION C OALITION (MCEC) MCEC helps families, schools, and communities support military children throughout their academic careers MCEC initiates innovation to advocate for military-connected kids – such as Living in the New Normal Institute (LINN-I)

30 S ESAME S TREET S T ALK L ISTEN C ONNECT

31 N EW P ARTNERSHIPS TO B UILD C OMMUNITIES OF C ARE Paving the Road Home, a program of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) Policy Academies bring together state-level teams of community mental health and substance abuse service leaders, DoD and VA representatives, and veterans service organizations Every US state and territory has attended at least one SAMHSA Policy Academy

32 W ORKING S TATE BY S TATE The North Carolina Focus Replication in Virginia and Beyond Working at the National Level o Joining Forces o Each of the Nations 152 VA Medical Centers will hold a Community Mental Health Summit before 9/15/2013

33 N EXT S TEPS : E VIDENCE -B ASED, E FFECTIVE C OMMUNITIES OF C ARE The first lesson: Identify military children The second lesson: No single approach to serving our nations military Look for synergy among multiple programs rather than choosing among approaches and services

34 R ECOMMENDATIONS : F ROM C LINICAL P ROGRAMS TO C OMMUNITIES OF C ARE 1. Clinicians should ask, Have you or someone close to you served in the military? 2. Military history and military family status should be highlighted in each persons medical record so that it is noted at each encounter 3. Incentivize military history taking to improve health outcomes and reduce healthcare costs 4. Teach all program staff about military culture and basic deployment mental health 5. Register the names of clinical programs that follow such guidelines in the National Resource Directory

35 R ECOMMENDATIONS FOR E DUCATIONAL, O CCUPATIONAL, C ONGREGATIONAL, L OCAL G OVERNMENTAL AND O THER C OMMUNITY S ETTINGS 1. Note military connection in school records 2. Employers and EAPs note military-connected employees 3. Clergy leaders be aware of the presence and contributions of military families 4. State and local governments train on military 5. Campus faculty and staff build on best practices 6. All governments and communities commit to fully update the National Resource Directory 7. Librarians in all settings promote the National Resource Directory

36 I MPLEMENTING S ALMON S V ISION PIE principles provide a strong foundation to build communities of care for military children Focus on recognizing military children and addressing their problems in close proximity to their homes, schools, community organizations and doctors offices Identify their needs with immediacy by watching for early warning signs of stress rather than waiting for the development of clinical disorders Proceed with high expectancy that military children will continue to cope, grow, and succeed as valued citizens of their communities and their nation

37 T HERE IS S UCH A T HING AS A M ILITARY C HILD Military children and their families constitute one of the largest American subcultures yet they are also one of the least visible These children are embedded in families and communities and in a military culture that values humility and self-sufficiency They strive to put the needs of others (including their military parents) above their own

38 E FFECTIVE C OMMUNITIES OF C ARE Measured by their public awareness of military children The distinguished physician and medical educator Francis Peabody once said that the secret of the care of the patient is caring about the patient The secret of creating communities of care for military children is creating communities that care about military children This will require effort and time, but we believe it is an attainable goal.

39 S UMMARY Defining Communities of Care History of a Public Health Perspective Building Communities of Care for Military Children Community of Care Domains Programs that contribute to Communities of Care Coordination and Recommendations across states throughout the Nation For clinical, educational, and governmental impact

40 QUESTIONS? Harold Kudler, MD: Harold.Kudler@va.gov Rebecca Porter, PhD: rebecca.i.porter2.mil@mail.mil


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