1. Northwest Network Post-Deployment Health Service Delivery Model
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2. Components of An Effective System of Care
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Components of An Effective System of Care
1. Administrative Infrastructure
2. Interagency Collaboration and Sharing Agreements
3. Coordinated Outreach Activities
4. Integrated System of Care:
-Primary Care vs. Specialty Mental Health Care
-VAMC-Based Care vs. Community Care
Interagency collaboration is necessary to minimize redundancy/maximize resources
Outreach serves to identify target cases early (increase chance of successful intervention) and establish and maintain relationships with community resources (ongoing)
Integrated system of care improves timeliness and effectiveness of interventions, reduces tx errors
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3. Administrative Infrastructure
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4. Interagency Collaboration Administrative Infrastructure
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Partners
Function
Mental
Health
Complicated/Severe cases
Patients who “accept” a PTSD Diagnosis
Specialized interventions
PTSD Inpatient and Outpatient programs
Addictions programs
General Mental Health
Voc Rehab Services
Uncomplicated cases
Screening, education, brief supportive Rx
Triage to Mental Health
Deployment Health Clinic
Spinal Cord Injury and RMS
Primary Care
Specialty Medicine
Seamless Transition Program
Vet Center & VA Outreach
Drill Weekends for Reserve Units
Community Outreach
Case Finding
Primary Care Screen
Family Activity Day
DoD screening
Educational resources
VA & WA State DVA
Vet Centers
DoD
Dept. of Labor
Interagency Collaboration
Sharing agreements
Cross referral
Educational meetings
The first three layers represent the content of this section of the presentation; we will address the primary care and mental health components in greater detail later in the presentation
Administrative Infrastructure
Resources
Organization
Mission priority
Network
Facility
MH Service
Military Director
Federal & State
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5. Foundation for an Effective Service Delivery System
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Foundation for an Effective Service Delivery System
Mission Priority (“Buy in” from leadership)
Organized Plan for Regular Communications (meetings of stake holders)
Resource Allocation Fitted to Work to be Accomplished
Sharing agreements & Inter-agency Collaboration
Leadership is crucial to both building and maintaining service delivery system with regular communication and resource allocation increasing the effectiveness of the system and sharing agreements facilitating delivery of care
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6. 9/18/2018
Examples of System Building 1. Northwest Network Deployment Health Summit
Two-Day Regional Conference (Nov. 8-9, 2004)
Purpose:
Familiarization of partners involved in health care of soldiers/veterans
Education about nomenclature, function, and roles of each agency
Inventory, map, and coordinate assets adjacent to concentrations of returning veterans
Identify unmet mental health needs of veterans and deficiencies in services
Develop an action plan for outreach and tailored interventions at facility, state, and regional levels (identifying resources needed and interagency sharing agreements to develop)
Inclusive, overlapping players communicate to establish common nomenclature (ongoing ) and educate each other about roles/assets
Proximity to veterans was emphasized (WA is a large, mostly rural state with geographic/transportation obstacles
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7. Constituents (returning combat soldiers) Regional VAMCs Vet Centers
Northwest Network Deployment Health Summit (Cont’d) Participating Stakeholders
Leaders from all branches of DoD (regular active duty and reserve component)
Constituents (returning combat soldiers)
Regional VAMCs
Vet Centers
State Department of Veterans Affairs
TriWest
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8. DOD and Washington National Guard Unit Locations Statewide
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DOD and Washington National Guard
Unit Locations Statewide
BELLINGHAM
C/898 EN
ANACORTES
C/898 EN
OKANOGAN
EVERETT
HHC 898 EN
215TH EIS
SPOKANE /
FAIRCHILD AFB
141 AW
242 CBSC
HHC/C IN
B/2-146 FA
B/1-303 AR
66th Avn BDE
341st MI
A/1-19 SF
791st Chem
SNOHOMISH
A/898 EN
POULSBO
McChord AFB
262nd IWAS
116TH WF
REDMOND
1-205th Reg (Ldr)
SEATTLE
81 HQ
HHC/A/C/181 BN
143RD CBCS
BREMERTON
B/303 AR
KENT
HHC AR
A/B/161 IN
281 MI
WENATCHEE
C/1-161 IN
PORT ORCHARD
B/303 AR
248 RAOC
TACOMA
Trp Cmd
341 MI
EPHRATA
1161 TC
PUYALLUP
E/303 CAV
Cheney
256th CBSC
SHELTON
BUCKLEY
A/1-19 SF
MOSES LAKE
C/1-161 IN
FORT LEWIS
81 REAR DET
66th Avn BDE
E/168 AV
B/14 EN
OLYMPIA
HHB FA
ELLENSBURG
116 RAOC
National Guard soldiers and airmen were deployed from 230 of the 240 cities in the state of Washington. This map shows the locations of the Unit Armories where they are stationed.
MONTESANO
A/2-146 FA
YAKIMA
B/181 BN
420 Chem BN
792 Chem Co
144th ARFOR
1-205th Reg (Ldr)
PULLMAN
B FA
CENTRALIA
A/2-146 FA
CAMP MURRAY – JFHQ
122 MPAD th ASOS’s
SOD PAC th ASOC
I/O GP rd MDF
1-205th Reg (Ldr) 252nd Group
254th Red Horse
TOPPENISH
HHC/1-161 IN
CLARKSTON
PASCO
A/1-303 AR
GRANDVIEW
791st Chem Co
LONGVIEW
C/2-146 FA
WALLA WALLA
A/1-303 AR
VANCOUVER
C/2-146 FA
792nd Chem
A/1-19 SF
CAMAS
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9. VAMC, Vet Centers, WDVA PTSD Program, WANG Family Support Sites
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VAMC, Vet Centers, WDVA PTSD Program, WANG Family Support Sites
Whatcom
San Juan
Pend
Oreille
Ferry
Okanogan
Skagit
Stevens
Island
Clallam
Snohomish
Chelan
Douglas
Jefferson
Kitsap
9 King County
PTSD Contractors
Lincoln
Spokane
Grays Harbor
King
Mason
Kittitas
Adams
Grant
Whitman
Thurston
Pierce
Pacific
Lewis
Yakima
Franklin
Garfield
Columbia
Wahkiakum
Asotin
Skamania
Benton
Walla Walla
Cowlitz
VAMC
Clark
Klickitat
RCS Vet Center
Joint WDVA and Vet Center Contractor
WDVA PTSD Outpatient Contractor Site
VA Community Based Clinic Site
WDVA PTSD Program Outpatient Remote Site
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10. Northwest Network Deployment Health Summit (Cont’d) Follow-Up Monitoring of Progress
Publication of Summit proceedings (contact info, action plan, resource lists, etc.)
Monthly conference calls with designated OIF/OEF points of contact in mental health (re: outreach efforts and effective models of clinical care)
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11. Quarterly Mental Health Consortium Meetings
Examples of System Building (Cont’d) 2. Cross Fertilization Activities with DoD, WDVA, TriCare
Quarterly Mental Health Consortium Meetings
Jointly Organized and Attended Regional Training Conferences
VAPSHCS GWOT Outreach Leadership Group
VA/DoD Collaborative Research (clinical trials)
Sharing Agreements for Clinical Care with DoD
VAPSHCS inpatient medicine service at MAMC
MAMC inpatient psychiatry service at VAPSHCS
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12. Examples of System Building (Cont’d) 3. Resource Allocation
VAPSHCS funded OIF/OEF Liaisons and facility POC
VACO funded level II Polytrauma Center
WA State DVA funds a Coordinator of the inter-agency MOU process
VACO-funded OIF/OEF mental health clinicians
Vet Centers fund GWOT outreach workers
WA State legislature expands funds for community-based PTSD contract providers
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13. Interagency Collaboration and Sharing Agreements
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14. 1. Interagency Memo of Agreement
Formal interagency agreement (MOU) that defines the mutually agreed upon requirements, expectations, and obligations of federal and WA state agencies to deliver social and health services to veterans.
Stipulates a coordinated plan for outreach, education, and clinical service delivery to members (including family) of the Washington State National Guard and reserve units.
Involved cooperative interagency planning, lead by WDVA.
Commitment to provide customer service, not just briefings, 3-6 months following deployment.
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15. Memo of Agreement (Cont’d) Participating Partners
Washington State Military Department
Washington State Department of Veterans Affairs
Department of Veterans Affairs (VHA and VBA)
Washington State Employment Security Department
U.S. Department of Labor
Washington Association of Business
Governor’s Veterans Affairs Advisory Committee
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16. Washington State MOU 9/18/2018
The Washington State MOU has been a continuing work in progress.
It’s purpose was to define mutually agreed upon requirements, expectations and obligations between the following entities in efforts to ensure the our military service members and their families are honored for their valuable and honorable service to our country.
Signed last November by:
* Washington Military Department
* Washington State Dept. of Veteran’s Affairs.
* Employment Security Dept.
* Employer Support of Guard and Reserves
* Dept. of Labor – VETS
* Veteran’s Benefits Admin.
* Veteran’s Healthcare Admin.
* Veteran Service Organizations
We organized quickly and efficiently.
We now have a MOU Coordinator who is the “Go To Person” and all events are coordinated through this process.
There are several outreach components involved in the MOU:
SRP: Soldier Readiness Process. Soldiers attend a series of classes and briefings, prior to and following their deployment, all of which are to help prepare them for their upcoming assignments or return to civilian life.
Reunion Training: The Washington NG Family Support Network recognizes that both service members and their families face readjustment issues following deployment. The goal of the program is to provide training at least thirty days prior to the service member’s return home. These events have been quite successful with high participation levels from family members. Very soon the second phase of the Reunion Trainings will begin and at this training the soldiers will attend with their spouses and/or parents.
There are several modules included in the training:
Reunion Stress
Combat Stress-Homecoming After Deployment
Reunion Finances
Family Reunion-Child Issues
Communication
Community Briefing & Open Forum
Freedom Salute Ceremony: is a program designed to honor our civilian soldiers for their outstanding service while deployed and to recognize the service and sacrifices of the families, local communities and businesses during the period of deployment. There is to be an agency presence from each partner of the MOU at each of these events that distribute information regarding services and/or benefits.
Family Activity Days: These events are being held on pre-established drill weekends at each local armory three to six months following the soldier’s release from active duty. This outreach activity is designed to provide service members and their families a comprehensive program to help them understand and access the various entitlements and programs that are now available to them as Washington State veterans.
Volunteer Training: We just received notification this past week that the first round of volunteer training has been scheduled. All MOU participants and volunteers are encouraged to attend this important training.
Adopt An Armory: Actually involves adopting the 10 Family Assistance Centers. Objective is to have Veteran Service Organizations and Civic Groups “adopt” Guard members and their families - Offering financial outreach, scholarships, grants, and civic programs.
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17. Coordinated Outreach Activities
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18. MOU-Driven Outreach Plan and Responsibilities
Directive to National Guard and reserve unit commanders by the Adjutant General:
Conduct Family Activity Day (FAD) briefings 3-6 months after deployment
Conduct health care screening at FAD events
WDVA provides a point of contact to the WA National Guard Family Support Network (respond to inquiries regarding benefits and assist Family Support Coordinator with emergencies).
WDVA provides a coordinator for FAD events.
WDVA sends letters to all recently discharged veterans in WA, signed by the Governor, Adjutant General, and Director DVA, describing services.
VA and other agencies send volunteers to FADs and provide follow-up social services
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19. Service Delivery Outcomes Family Activity Day Events
23 total FAD events for 32 units (during 2005)
Average 18 volunteers per event
Total participants at FAD events = 2,055
Outcomes from the 10 FAD events held 2005:
Mental health referrals made to 856 participants (42% )
On-site enrollment in VHA health care for 1061 participants (52%)
On-site filing of claims for compensation for 360 participants (18%)
On-site employment assistance provided to 449 participants (22%)
TriCare briefings to 1862 participants (84%)
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20. Health Screening and Triage at FAD
PDHRA Administration
Automated Scoring with Instant Feedback
On-Site “Second Tier” Screening and Triage
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21. Priority 1 = 20% Priority 2 = 25% Priority 3 = 55%
Case Identification of DoD Returnees (Cont’d) Army National Guard Outcomes
Health Risk Appraisal Results (N = 1,457):
Priority 1 = 20%
Priority 2 = 25%
Priority 3 = 55%
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22. Current Number and Percentage of Total Referrals to Date by Facility
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2. Seamless Transition Program at MAMC (Total VA health care referrals = 3,156 [Sept-03 – 7-Apr-06])
1. Since September 2003, 44% of all referrals that have been made nationwide have been generated out of MAMC. This is largely due to the teamwork that has developed between VA and DoD partners and the fact that MAMC serves the largest proportion of the “walking wounded” (soldiers who are in need of outpatient care and/or rehab).
Current Number and Percentage of Total Referrals to Date by Facility
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23. 3. Other Outreach Activities (Cont’d)
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3. Other Outreach Activities (Cont’d)
Leadership training for reserve component unit commanders
Assign an “on call” mental health professional to National Guard squad leaders
Soldier Readiness Processing Briefings (Ft. Lewis)
Education, enrollment, and intervention at DoD medical hold company
Regional job fair for all veterans separated from active duty
Educational presentations: VSO groups, community providers, and police departments
Telephone-Based Tobacco Cessation Counseling to OIF/OEF Veterans
Leadership Training:
To identify signs of stress and refer service members to state or federal resources
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24. 4. Educational Resource Materials
Post-Deployment Handbook
Pocket Card
WDVA Website
VAPSHCS Deployment Health Clinic Website and Handbook
Vet Center DVD Educational Program
VISN-Wide Standardized Powerpoint Slide Show
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25. Post-Deployment Readjustment Successful Coping Strategies
Educational Presentation to DoD Audiences “Homecoming After Deployment” Powerpoint
Post-Deployment Readjustment
Successful Coping Strategies
When to Get Professional Help
Where to Turn for Assistance
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26. Integrated System of Care
Reorganize Existing Programs
Develop Innovative Programs
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27. Reorganize Existing Programs
Emergency Bed on EBTPU
After hours clinics improve access to care
Telephone-based care
Accommodation to brief individual forms of therapy
Implement a “stepped care” approach
Wellness-oriented brief group treatment (manual driven)
Prescribers detailed to Vet Centers (with telemedicine links)
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28. PTSD Specialty Services
PTSD Outpatient Clinic
PTSD Inpatient Evaluation and Brief Treatment Unit
PTSD Domiciliary
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29. PTSD Outpatient Clinic Seattle VA Medical Center
Post-Deployment Readjustment Class
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30. Table of Contents Topics
How to Use this Manual
Topics
Class Introduction (2 sessions)­­­
Medications (1 session)
Goal Setting (1 session)
Health and Wellness (1 session, plus one optional session)
Sleep Hygiene (1 session)
Mood Management (2 sessions)
Anger Management (2 sessions)
Relationships (1 session)
Graduation (1 session)
Handouts
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31. The PTSD Evaluation/Brief Treatment Unit
Puget Sound Health Care System
Benefits and Challenges of Integrating OEF/OIF Veterans into Existing Mental Health Treatment Programs
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32. Operational Characteristics
Primarily group-based treatment
Incorporates psychoeducation, group psychotherapy, and trauma-focused therapy to address symptoms of PTSD
Average length of stay is 17 days
To date: Patients-mostly male VN era veterans
Staff (2 clinical psychologists, 1 social worker, psychiatric nurses, 1 physician’s assistant, 1 psychiatrist, and 1 Recreation therapist)
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33. Commonalities Nature of combat experiences
combatants not immediately identifiable
Guerilla tactics
Sociopolitical context of wars
Divisions in public attitudes toward war
Changing timelines and goals of military efforts
Marked Cultural/Ideological/Religious differences
Media coverage
Public access to images of war
Scandals involving war crimes
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34. Differences Volunteer/Career Military Media/Communications
Broader range of ages, education, SES, previous training, gender
Media/Communications
Significantly less delay in reporting
, telecommunication options
Symptom profiles
Acute re-experiencing and hyperarousal symptoms, less entrenched avoidance behaviors
novelty of symptoms with recent recall of premorbid functioning
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35. Challenges to Integrated Treatment
Differences in experiences, life stage, and duration of symptoms
Can interfere with group cohesion
Differences in the VA’s administration of treatment for OIF veterans
Screening, outreach, psychoeducation
Responsiveness of the VA system to OIF/OEF veterans (priority cases) and VN veterans reactions
Empirically supported pharmacological and psychosocial treatments for PTSD
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36. Benefits of Integrated Treatment
Mentoring:
Provides older veterans (e.g., Korea, VN, Gulf War I) opportunities to provide support and guidance to younger veterans
Guidance:
Younger veterans are able to take advantage of the information/experiences of older veterans
Insight:
Increased insight and acceptance of symptoms (e.g., similarities across age, cohort, military contexts).
Interpersonal Issues:
Unique opportunities to address and resolve interpersonal, intergenerational themes (i.e., father-son relationships)
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37. Differences in Treatment Approaches for OIF/OEF Veterans
Prioritizing most immediate/current issues
Stabilization of Acute Psychiatric Symptoms
Occupational and financial functioning
Relational functioning (divorce, infidelity, domestic violence)
Substance abuse issues; legal issues
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38. Emphasis on Individualized Treatment Approaches
Flexible, hierarchical approach to CBT therapy for PTSD: Exposure therapy?
Type of interventions dependent on acuity of symptom severity and recentness of trauma exposure with an acknowledgement of recovery without psychotherapy (e.g., Flack, Litz, & Keane, 1998; McNally, Bryant, & Ehlers, 2003)
Veterans’ perceive fewer benefits of trauma-focused therapy compared to action-based, skills focused treatments (see Johnson & Lubin, 1997; Johnson, Lubin, James, & Hale, 1997).
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39. Develop Innovative Clinical Programs
1. Deployment Health Clinic
2. Level II Polytrauma Center
3. Telephone-based tobacco cessation intervention
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40. VA PSHCS Mental Health Services for OIF/OEF Veterans Organizational Diagram
Vet Centers
Seattle
Tacoma
Bellingham
Yakima
Spokane
VA PTSD Programs
PTSD Clinical Teams
Women’s Trauma Team
PTSD Inpatient Unit
PTSD Domiciliary
State Dept. Veterans Affairs
29 contract therapists
Affiliated Mental Health Programs
Addictions Programs
General Mental Health
Post-Deployment Clinic
Primary medical care
Mental health screening/triage
Brief therapy & meds management
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41. Outcomes Monitoring Descriptive Information:
Number of outreach briefing events
Number of veterans educated
Rates of enrollment linked to outreach events
Workload for VAPSHCS, vet center, and WDVA
Symptom monitoring NEPEC measures
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42. Facility and Network OIF/OEF Workload Data FY02 Through (3/31/06)
VAPSHCS treated 4,645 vets any condition (ranked 3rd in nation)
VAPSHCS treated 445 vets for PTSD (ranked 3rd in nation)
Regional Vet Centers in VAPSHCS area treated 264 vets for PTSD
VISN-20 treated 1,623 unique veterans with PTSD (VAMCs + Vet Centers) (ranked 6th in nation)
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