1. Deployment Mental Health and Homelessness: Making the Vital Connection 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 million living Veterans, 8.9 million (40%) are enrolled in VA Healthcare Nearly three-quarters served during a war or an official period of conflict VA currently provides health care to 6.3 million veterans (29%) www.va.gov

3. OEF/OIF/OND Veterans In VA As of December 31, 2013: 18 million of 2.5 million total OEF/OIF/OND Veterans eligible for VA services 58% (1,027,801) 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 55.7% (572,569) of the 1,027,801 eligible OEF/OIF/OND Veterans who have presented to VA Provisional MH diagnoses include: PTSD (30% of all who presented to VA) 311,688 Depressive Disorder 248,891 Affective Psychoses 152,587 Neurotic Disorders: 229,361 Alcohol Dependence: 72,055 Nondependent Abuse of Drugs: 53,839 Tobacco Use Disorder 149,714

5. Our Focus: Deployment MH PTSD TBI Depression Grief Family SUD MST Homeless Job Chronic Pain

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 58% of OEF/OIF/OND Veterans eligible for VA care have come to VA where are the other 42%?

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

11. 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 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?

12. 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 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., & Cornelison- Grant, V. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research & Treatment Center, 2011

13. 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

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 third (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. 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

17. 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

18. Needed: On behalf of Service Members, Veterans and their families: Military and Veteran friendly principles and practices as part of a public health intervention

19. Treating the Invisible Wounds of War www.aheconnect.com/citizensoldier www.aheconnect.com/citizensoldier Free, accredited on-line trainings: Military Families Deployment Mental Health Deployment Primary Care Women Veterans Employment Assistance Programs 20,000+ community providers and stakeholders have completed at least one training National HRSA Grant trained 11,000+ more community providers

20. Searchable Provider Database at www.WarWithin.org 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

22. 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 Training: www.deploymentpsych.org/military-culturewww.deploymentpsych.org/military-culture

23. 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

24. 24 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?” ) 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

25. Key VA Websites for Community Providers http://www.mentalhealth.va.gov/ communityproviders 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

26. Painting a Moving Train 26

27. The Big Blue Button 27

28. Focus On Homeless Veterans VA Services for Homeless Veterans were originally part of Mental Health but has grown to incorporate broader questions central to addressing the needs of Veterans and their families These include: Health services beyond Mental Health Housing Initiatives Grant & Per Diem HUD VASH Jobs Family Services Community Outreach

29. Applying the Public Health Model to Homelessness If state and local programs for the homeless don’t ask every client if they or someone in their family is a Veteran (a spouse, a parent, a child), they are less likely to find their way to VA Homeless services If organizations collect this information but don’t/can’t share it with VA, it can’t be put to good use Community providers need to know that Veterans are particularly vulnerable to homelessness which may come at the end of a downward spiral years after return to civilian life Women Veterans are at greater risk of Homelessness than the average American Woman Community partners in every aspect of homelessness should know something about military culture, military history, possible effects of deployment stress on Service Members and their Families and deployment- related MH issues including Substance Abuse

30. VA Homeless Coordinators and Community Partners Have a Unique Opportunity to Drive Public Health Principles and Transform National Models of Care Recognizing Veterans and their families in the community (including among the Homeless) and preserving them as families may be the first and most critical step in engaging Veterans in effective action on deployment-related mental health problems such as PTSD, TBI and substance abuse The Veteran’s perceived social support from his/her family is one of the strongest predictors of either not having PTSD or of positive outcomes in PTSD This “Families and Housing First” perspective is a core component of the Public Health model

31. While Doing This, Remember: Veterans should not be discharged from housing programs because of mental health issues, substance abuse or minor violations Rather, these problems should drive new opportunities for Veteran care and Community Partnership Clinical and administrative experience teach that the treatment of comorbid PTSD, Substance Abuse and Homelessness is most successful when it is integrated rather than broken into successive steps This idea is enshrined in the term “Housing First”! Believe it! Preserving a family preserves a home!

32. 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!

33. QUESTIONS?