Army National Guard Case Manager Workshop 19 June 12

1. Army National Guard Case Manager Workshop19 June 12 LTC Laura Wheeler, LCSW Chief, Behavioral Health Office of the Chief Surgeon 703-607-9535 laura.a.wheeler@us.army.mil

2. Presentation Objectives • Review definition and basic information regarding Traumatic Brain Injury (TBI) and Post Traumatic Stress (PTS) • Improve the understanding of the impact of mild TBI (mTBI)/ and PTS on the Soldier and nit • Provide coding tips and examples • Identify resources

3. National Guard Manpower Army National Guard 77% 350,000 Air National Guard 23% 107,000 • Majority of Guard members are “traditional” or “part-timers” • 80-85% traditional; 15-20% Active Duty (AGR – Active Guard and Reserve – T32 at State level)

4. DoD Defintion (2007) of TBI • A traumatically induced structural injury and/or physiological of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event: • 1. Any period of loss of a decreased level of consciousness (LOC) 2. Any loss of memory for events immediately before or after the injury [post-traumatic amnesia PTA] 3. Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.) 4. Neurological deficits (e.g., weakness, loss of balance, change in vision, sensory loss, aphasia)

5. DoD Definition (2007) of TBI (con’t) • Common Behavioral/Emotional Symptoms • Depression • Anxiety • Agitation • Irritability • Impulsivity • Aggression

6. mTBI Information • Over 91,000 RTD Soldiers have been diagnosed with mTBI since 2000 • The term mild does not describe the symptoms, but rather the injury sustained • The majority of Soldiers can expect a full recovery • Intervention for soldiers with persistent symptoms after concussion requires multidisciplinary care

7. National-Center for PTSD Post-Traumatic Stress Disorder • Classified with the anxiety disorders • Occurs in 3-6% of adults in the United States • Twice as common in women as in men • Rates as high as 58% in for those who have experienced heavy combat • Occurs in up to 14% of service members who have not seen combat • Occurs in up to 75% of those who have experienced torture or been a prisoner of war • 4-16% of victims of natural disaster develop PTSD

8. Post-Traumatic Stress Disorder (con’t) • Exposure to a traumatic event in which the person experienced, witnessed, or was confronted by death or serious injury to self or others AND responded with intense fear, helplessness or horror. • KEY Features: - Symptoms appear in 3 clusters: re-experiencing, avoidance/numbing, hyperarousal - Symptoms last for > 1 month - Symptoms cause clinically significant distress or impairment in functioning

9. Identifying Symptoms of TBI to PTSD mTBI PTSD Insomnia Memory Deficits Poor Concentration Depressed Mood Anxiety Irritability Intrusive symptoms Emotional Numbing Hyperarousal Avoidance Behavior • Insomnia • Memory Deficits • Poor Concentration • Depressed Mood • Anxiety • Irritability • Headache • Dizziness • Fatigue • Noise/Light Intolerance

10. At Risk Warning Signs • Warning signs for Leaders: • ƒComments that suggest thoughts or plans of suicide • ƒGiving away possessions • ƒObsession with death, dying, etc. • ƒUncharacteristic behaviors (e.g., reckless driving, stealing) • ƒSignificant change in performance • ƒAppearing overwhelmed by recent stressor(s) • ƒDepressed mood; hopelessness • ƒWithdrawal from social activities • Warning signs that someone needs help: • Noticeable changes in eating and sleeping habits • Talking or hinting about suicide • Obsession with death (e.g., in music, poetry, artwork) • Irritability • Alcohol and/or drug use or abuse • Isolation • Giving away possessions/suddenly making a will • Feeling sad, depressed, or hopeless • Non-verbal body language presence, poor hygiene

11. Key Factors Affecting Utilization • Lack of awareness of services • Multiple programs/redundancy • Minimal staff for state coverage • Stigma • Confidentiality • Financial Challenges • Information/Education • -Clinical • -Policy: Duty status, Title 10/Title 32 • -Geography

12. Armories and Wings are community-based Locations are seldom within the catchments’ area of a military treatment facility Non-provision of health care treatment All care is received externally through TRICARE, the Veterans Health Administration, and health insurance provided through a Guard member or spouse’s civilian employer Varying degrees of capability between communities Psychological health is not a core competency Inconsistency between a state’s ability to design and implement a psychological health program NG Psychological Health Challenges

13. DoD Psychological Health Concept

14. NG Psychological Health Relationship Model OSD, P&R OSD, HA OSD, RA Federal Partners Partnership Funding NGB JSG Policy, Oversight, Guidance ARNG/ANG Direct Resources DPH Contractors States, Territories, & D.C. States, Territories, & D.C. States, Territories, & D.C. States, Territories, & D.C. Coordination, Collaboration, & Communication States, Territories, & D.C. 89 Wings, 54 States, Territories, and District of Columbia

15. NGB Psychological Health Mission To advocate for and support NG members and families by promoting mental fitness and personal wellness for operational readiness Develop community-based behavioral health networks Educate NG members and their families Assess and refer NG members (families) who may have behavioral health issues Conduct Leadership Education and Training Build psychological health fitness and resilience while dispelling stigma Document and track data to provide quality services and identify needs/trends Disaster Behavioral Health Health Receive military culture training to service National Guard members appropriately as part of the contract DPH Functions

16. Current State DPH Status VT WA ME AK ND MT NH MN OR MA WI MI NY RI ID SD CT WY PA NJ IA DE OH NE NV IN MD IL UT DC WV VA CO CA KS MO KY NC GU TN OK SC NM AR AZ HI GA MS AL LA TX FL Green = DPH Service Yellow = Hiring Decision PR VI

17. Case Management • Monitor and support Guard members • Follow-up services related consultation and referral success • Vetting referral sources; training community providers on military issues • DPH is a part of the State Surgeon/G1, J1, and J9 multi-disciplinary team • SS, CM’s DSS, BHO, Chaplains and FP • ARNG-CSG has PDHRA/PHA, CM, AA tracking of emergent and high risk referrals • Developed a BH sensitive folder in HRR

18. NGB Psychological Health Partners • Sustainable BH/PH Program • NGB Joint Surgeon • Policies, Procedures and Guidance • Direct Resources aka Execution by States/Wings • Reserve Component Consortium model • POTUS • Strengthening Our Military Families: Meeting America’s Commitment • Legislative Initiatives • S. 325, H.R. 948: Sen. McCaskill (MO) and Sen. Murray (WA) • Suicide Prevention offer: Sen. Casey (PA) • Joining Forces for Military Mental Health Act: Sen. Reed (RI)

19. NGB INTEGRATED SERVICES DELIVERY MODEL State Coalition HHS VISN Mental Health PHS SFPD DPH Governor’s Office Family Readiness Volunteers Child and Youth Vet Center Federal Services ESGR National Guard Services State Directors Mental Health and Substance Abuse Adjutant General NCA State Directors Of VA NG Chaplains VHA VBA FACs Legal Services National Guard STATE JOINT FORCE HEADQUARTERS Army Community Service Financial Services Training Support MPF/’ MILPO Fed, State, Local & Private Orgs. Services Information VSO Military Medical Community Medical Hold (CBHCO) All assets in support of the NG member and families TRICARE Community Services DoD Services AW2: Army Wounded Warrior Civilian Medical Community Community Mental Health WTU Military Severely Injured Center Air Wounded Warrior Military One Source

20. Transition Assistance Chaplains Family Programs Sexual Assault Response State Medical Soldiers and Airmen Employer Support Yellow Ribbon State/Wing Psychological Health State and Wing Guard Teams

21. ARNG SUPPORT PROGRAMS/Initiatives • Soldier Family Support Division: R3SP Campaign Plan: The R3SP Campaign Plan redefines suicide prevention as an intergrated part of a broader based resilience and risk reduction framework. • Master Resilience Trainers: In FY11, the ARNG established, a master Resilience Trainer (MRT) Training Center at Fort McCoy, Wisconsin. Currently the ARNG has over 1,000MRTs. • Vet4Warriors: V4W is a peer support line that provides all National Guard and Reserve Component Service Members, direct access to supportive, non-attributional, conversations with well-trained veteran peers who share similar experiences. • National Guard Employment Network : Serves as a Comprehensive Job and Training Resource for Soldiers and Families. • SAMSHA: Assist National Guard State/Territories in forming collaborative relationships with all entities that provide BH services and benefits for NG members and their families • RR/IST: Tracking checklist • ARNG:Recruiting and retention

22. SAMHSA-NGB MOU: Official Memorandum of Understanding (MOU) NGB-HHS, SAMHSA Signed 18 NOV 2009 Establish a framework to for the BH needs of NG members and their families. The main goals: • Assist National Guard State/Territories in forming collaborative relationships with all entities that provide BH services and benefits for NG members and their families • Preparing community and State providers to offer informed care to this population (i.e., through training resources, etc.) • Developing a mechanism for data and information exchange between the National Guard and States.

23. Military Families A Sampling of Accomplishments-SAMHSA • Strong partnership with VA: National Suicide Prevention Lifeline and Veterans Crisis Line; Interagency Agreement. • Member of Military/Veteran Task Force of National Action Alliance for Suicide Prevention, leading the momentum to engage faith-based communities in supporting Military Families. • Conducted third Service Members, Veterans and their Families Policy Academy in Dec 2011. • Manage a national technical assistance center to help states/territories enhance their behavioral health care systems for service members, veterans, and their families. • 22 out of the 30 current Access to Recovery (ATR) grantees have designated National Guard, Reserves, Active Duty, Veterans and their families as a priority population. (Treatment vouchers for substance abuse treatment.) • Military Cultural Competence: Train ATR grantees (webinars and Tennessee’s Operation Immersion). Operation Immersion has spread to at least 4 other states.

24. Other Initiatives • E-Benefits • In-Transition • Telehealth • DCoE Study • Axhill Study

25. Representation, Collaboration and Communication RC internal partnerships and strategies RC representation within the OSD RC legislative initiatives NGAUS/EANGUS

26. Resources • Vets4Warriors:www.vets4warriors.com 1855-VET-TALK (1855-838-8255) • Military OneSource www.militaryonesource.com 1800-342-9647; Overseas 1800-342-6477; Collect Call 1-484-530-5908 • DCoE:http://www.dcoe.health.mil/ 1866-966-1020 • SuicideOutreach.org 1800-273-TALK (8225)

27. Resources (con’t) • www.ptsd.va.gov • https://www.ebenefits.va.gov • www.health.mil/intransition • www.dvbic.org • www.womenshealthva.gov • www.hooah4health.com • SAMHSA’s Military Families Strategic Initiative, Service Systems Development Program: http://www.samhsa.gov/militaryFamilies/factSheet.aspx • Supportive Services for Veteran Families (SSVF) program www.va.gov/homeless/ssvf/asp • www.t2health.org (Telehealth Services) • Sesame Street-Talk, Listen, Connect www.sesameworkshop.org/initiatives/emotion/tlc • After deployment: http//www.afterdeployment.org/ • Tricare: http://www/tricare.mil/providers/

28. Questions • Questions?

29. Other Information • LTC Laura Wheeler, LCSW ARNG,Office of the Chief Surgeon 703-607-9535 laura.a.wheeler@us.army.mil • Cheryl Marrow, LMFT, LPC NGB Psychological Health Program Senior Policy Liaison 703-607-5288 cheryl.l.marrow@us.army.mil