MICHAEL J. KUSSMAN, MD
DEPUTY UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS' AFFAIRS
VA MENTAL HEALTH SERVICES
COMMITTEE ON VETERANS AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
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.
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.
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.
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.
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.
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.