Northwest Network Post-Deployment Health Service Delivery Model

1. 11/8/2011 VISN 20 MIRECC Smoking Cessation 1 Northwest Network  Post-Deployment Health Service Delivery Model

2. 11/8/2011 VISN 20 MIRECC Smoking Cessation 2 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 errorsInteragency 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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4. 11/8/2011 VISN 20 MIRECC Smoking Cessation 4 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 presentationThe 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

5. 11/8/2011 VISN 20 MIRECC Smoking Cessation 5 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 careLeadership 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

6. 11/8/2011 VISN 20 MIRECC Smoking Cessation 6 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 obstaclesInclusive, 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

7. 11/8/2011 VISN 20 MIRECC Smoking Cessation 7 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

8. 11/8/2011 VISN 20 MIRECC Smoking Cessation 8 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. 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.

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10. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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)

11. 11/8/2011 VISN 20 MIRECC Smoking Cessation 11  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

12. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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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14. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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.

15. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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

16. 11/8/2011 VISN 20 MIRECC Smoking Cessation 16 Washington State MOU 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. 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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18. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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

19. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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%)

20. 11/8/2011 VISN 20 MIRECC Smoking Cessation 20 Health Screening and Triage at FAD PDHRA Administration Automated Scoring with Instant Feedback On-Site �Second Tier� Screening and Triage

21. 11/8/2011 VISN 20 MIRECC Smoking Cessation 21 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%

22. 11/8/2011 VISN 20 MIRECC Smoking Cessation 22 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).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).

23. 11/8/2011 VISN 20 MIRECC Smoking Cessation 23 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 resourcesLeadership Training: To identify signs of stress and refer service members to state or federal resources

24. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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

25. 11/8/2011 VISN 20 MIRECC Smoking Cessation 25 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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27. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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)

28. 11/8/2011 VISN 20 MIRECC Smoking Cessation 28 PTSD Specialty Services PTSD Outpatient Clinic PTSD Inpatient Evaluation and Brief Treatment Unit PTSD Domiciliary

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31. 11/8/2011 VISN 20 MIRECC Smoking Cessation 31 Benefits and Challenges of Integrating OEF/OIF Veterans into Existing Mental Health Treatment Programs The PTSD Evaluation/Brief Treatment Unit Puget Sound Health Care System

32. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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)

33. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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

34. 11/8/2011 VISN 20 MIRECC Smoking Cessation 34 Differences Volunteer/Career Military Broader range of ages, education, SES, previous training, gender Media/Communications Significantly less delay in reporting Email, telecommunication options Symptom profiles Acute re-experiencing and hyperarousal symptoms, less entrenched avoidance behaviors novelty of symptoms with recent recall of premorbid functioning

35. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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

36. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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)

37. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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

38. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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).

39. 11/8/2011 VISN 20 MIRECC Smoking Cessation 39 Develop Innovative Clinical Programs  1. Deployment Health Clinic 2. Level II Polytrauma Center 3. Telephone-based tobacco cessation intervention

40. 11/8/2011 VISN 20 MIRECC Smoking Cessation 40 VA PSHCS Mental Health Services for OIF/OEF Veterans Organizational Diagram

41. 11/8/2011 VISN 20 MIRECC Smoking Cessation 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

42. 11/8/2011 VISN 20 MIRECC Smoking Cessation 42 Facility and Network OIF/OEF Workload DataFY02 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)