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Community Health Care Providers and Military Cultural Competence: Findings from a Web-Based Survey of Provider Needs Harold Kudler, M.D. Associate Director,

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Presentation on theme: "Community Health Care Providers and Military Cultural Competence: Findings from a Web-Based Survey of Provider Needs Harold Kudler, M.D. Associate Director,"— Presentation transcript:

1 Community Health Care Providers and Military Cultural Competence: Findings from a Web-Based Survey of Provider Needs 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

2 A Little History Joint DoD/VA Planning for the First Gulf War, Ft. Benjamin Harrison, December 1990 Military Medical System to “saturate” after two weeks of combat VA system to provide next fallback National Disaster Management System (NDMS) would then progressively enlist the efforts of every medical system in the nation including university and community hospitals and practices As a Nation, we dodged this bullet but where are we now?

3 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 (roughly 1 in 3) 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 (roughly 1 in 4 Veterans)

4 4 OEF/OIF/OND Veterans In VA Approximately 54 percent (771,874) of all eligible OEF/OIF/OND Veterans (includes Reserve Component Members) have used VA health care since October 1, 2001 A total of 476,811 of these accessed VA care during calendar year 2011 Those who use VA care seem to value it 52% (434,552) of all OEF/OIF/OND Veterans who have presented to VA have received at least one provisional Mental Health diagnosis health-care-utilization/index.asp

5 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 54% of OEF/OIF Veterans eligible for VA care have come to VA where are the other 46%?

6 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

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9 N=37,510

10 Service Members, Veterans and their Families are Distributed Across the Entire Nation and Many Seek Care Within Their Own Communities An estimated 25-50% of OEF/OIF/OND Veterans seen in DoD/VA also receive part of their care in the community Family members also deal with deployment- related 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?

11 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 Internet Link: Funded by VA’s Office of Rural Health Kilpatrick, D.G., Best, C.L., Smith, D.W., Kudler, H., & Cornelison- Grant, V. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research & Treatment Center, 2011

12 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

13 The Rural Dimension Rural Veterans 41% of all VA enrollees 39% of enrolled OEF/OIF/OND Veterans Rural Service Members (including Guard and Reserve Members), Veterans and their families are less likely to have access to a local mental health professional

14 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 in three (31%) had any VA training Only one out of eight (12%) have ever been employed as a health professional in VA

15 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”

16 An Important Educational Opportunity The largest group of providers (48%) reported “no hesitancy” in referring patients to VA health care but: 34% percent had neutral responses about referring to VA Providers with neutral opinions can be converted to advocates if provided with more information More than half of all respondents (58%) want to know more about eligibility requirements for VA care

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 Disparities in Knowledge and Confidence Among Community Providers: Rural Matters! Rural Providers were significantly more likely than Non-Rural providers to disagree that they were knowledgeable about best practices in treating depression, substance abuse/dependence and suicide 26% of Rural Providers disagreed with the statement that they felt knowledgeable about treating depression vs. 16% of Non-Rural Providers 26% of Rural Providers disagreed with the statement that they felt knowledgeable about treating substance abuse/dependence vs. 15% of Non-Rural Providers 37% of Rural Providers disagreed with the statement that they felt knowledgeable about managing suicide vs. 24% of Non-Rural Providers

19 Disparities in Knowledge and Confidence Among Community Providers: Rural Matters! No significant differences in professed knowledge on treating PTSD, TBI or Family Stress & Relationship Problems BUT: Rural Providers were significantly less confident about treating PTSD than their Non-Rural counterparts 46% of Rural disagree about confidence vs. 35% Non-Rural Rural Providers were also significantly less confident about treating depression 26% of Rural disagree about confidence vs. 15% Non-Rural The same pattern held for confidence about managing suicide 37% of Rural disagree about confidence vs. 24% Non-Rural

20 If You Don’t Take the Temperature, You Can’t Find the Fever Community Providers should ask every patient: Have you or someone close to you ever served in the Armed Forces? Potentially the key driver of change in practice!

21 Next Steps Implementation Science Approach Can we change provider practice by Increasing rate of screening for Military History? Increasing rate of referral to VA? Can we improve deployment health outcomes? Public Health Orientation Can we engage the entire DoD/VA/State and Community Continuum of Care in deployment mental health?

22 Challenges in Future Studies Access a representative sample of sufficient size Randomization that allows for analysis of: Rural vs. Urban Mental Health vs. Primary Care Health disparities by race, ethnicity and gender

23 Challenges in Future Studies Design an Appropriate Intervention Veteran Driven Place sign in waiting room If you or someone close to you has served in the military, please tell us. We want to know. Academic Detailing Office visits by colleagues (through professional organizations) vs. Veterans (individually as peer advocates or through Veterans Service Organizations), Family members or other stakeholders Evidence-Based Teaching Conduct survey of Military/Veteran and Family treatment preferences and send findings to community providers

24 Draft Referral Guide for Community Providers: Framing Desired Behaviors in 6 Point and Click Terms 1.For Veterans, friends or family members looking for information, resources, and solutions to issues affecting their health, well-being, and everyday lives—all in the words of Veterans: Make the Connection.Net 2.For OEF/OIF/OND Veterans ready to enroll in VA Care: rvicemembers.asp rvicemembers.asp 3.For Veterans of all other Service Eras ready to enroll in VA Care: https://www.1010ez.med.va.gov/ Phone, mail, web-based or in-person assistance in enrollment

25 Draft Referral Guide for Community Providers: Framing Desired Behaviors in 6 Point and Click Terms 4.If You are in an Emergency or Homeless: Veterans Crisis Line If You are a Family Member concerned about a Veteran: Coaching Into Care: or 6.If you are less than honorably discharged, unsure about your eligibility or would like to learn more about VA services: Vet Center: WAR-VETS( )

26 Measureable Outcomes Increased screening for Military Service and Family status Increased rate of referral to VA services Increased Training on Military Cultural Competence DoD/VA Military Cultural Competence Course Increased engagement in VA clinical consultation Make The Connection VLER: Virtual Lifetime Electronic Record Shares select parts of a Veterans’ medical record electronically with other approved health care facilities that are members of the Nationwide Health Information Network MyHealtheVet and Secure Messaging Dual Care ub_ID=2058 ub_ID=2058 Increased satisfaction in collaboration with VA VA is there to complement the provider’s care, not compete with it

27 Modest Proposal for A Pilot Project in Partnership With MCEC in Support of Service Members, Veterans and their Families Survey of current practices including screening for military history and referrals to VA Training of Membership Distribution of “The Sign” Academic Detailing by Health Professionals and/or Guard Members Clocking Referrals Creating a Tear Sheet Referral Form Tracking Patient Follow Up With VA AND Local M.D.s Tracking Patient Health Outcomes

28 New Principles As a nation, we need to promote a public health approach to bringing war fighters home that looks beyond the DoD/VA continuum of care to engage the entire community and all of its health care assets This follows from acknowledgment that, as citizens: We are all part of these wars We are all responsible for the care of Service Members, Veterans and their families We each have a role to play in promoting reintegration and resilience before, during and after deployment A modern Military Saying: The Military goes to war; the nation goes to the mall

29 The Vision 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!

30 QUESTIONS?


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