Harold Kudler, MD.

1. Building Communities of Care: Public Health Perspectives and Clinical Practices in Support of Military Children and Their Families Harold Kudler, MD. Associate Director, VA Mid-Atlantic Mental Illness Research, Education and Clinical Center and Duke University Durham, NC Rebecca I. Porter, PhD. Commander, Dunham United States Army Health Clinic Carlisle Barracks, PA

2. Agenda • Defining Communities of Care • History of a Public Health Perspective • Building Communities of Care for Military Children • Community of Care Domains • Programs that contribute to Communities of Care • Coordination and Recommendations • Across states • Throughout the Nation • For clinical, educational, and governmental impact

3. Pediatrician-Turned-Child Psychoanalyst D.W. Winnicott Once Said: There is no such thing as a Baby • No child exists in isolation • Military children develop through their relations with their military parents, other family members, caretakers, schools, communities, and the culture and operational tempo of the armed forces • That’s what makes them military children

4. Thinking Present and Future • DoD estimates that 57 percent of active duty troops serving in 2011 were the children of current or former active-duty or reserve service members • To understand and promote the growth and health of military children, for their sake and for the sake of our nation, we must consider interactions that extend across families, communities, culture and time • How does a nation develop communities of care that maximizeresilience and minimize the health risks that military children and their families face?

5. Defining Communities of Care • We define Communities of Care as complex systems that work across individual, parent/child, family, community, military, national and even international levels of organization to promote the health and development of military children

6. A Historical Precedent • Military medical history demonstrated long ago that merging clinical and public health approaches can effectively help service members cope with the stress of deployment • An outstanding example is the work of Dr. Thomas Salmon who served as chief consultant in psychiatry for General Pershing’s American Expeditionary Force during World War I

7. A Lesson from World War I • European military medical experts approached shell shock through a clinical model • Soldiers stayed in the trenches until they developed all its signs and symptoms

8. A Health Surveillance Strategy Aligned with Military Culture • Attention and prompt action were instrumental to helping their buddies, helping their units and accomplishing their mission • Military culture sees the health and success of the individual as inseparable from the health and success of the group: fertile ground for merging clinical and public health models of care

9. As Easy as PIE • Salmon’s doctrine of proximity, immediacy and high expectancyof success came to be known as the PIE model and remains a central principle of combat medicine today • Combat Stress Control Teams across Iraq and Afghanistan have a 97 percent return-to-duty rate

10. Building Communities of Care for Military Children • To apply Salmon’s principles to military children, we must first determine where their “front lines” are, identify the clinical and public health supports available to them, and apply a few basic tenets: • Allwarfighters and all of their family members (including children) face difficult readjustments in the course of the deployment cycle • Population-based approach is less about diagnosing an individual patient than about helping individuals, families, military units, and entire communities retain or regain a healthy balance despite the stress of deployment • In the life of the family and the child, each developmental step builds on the relative success of previous steps

11. Dynamic Principles in Working with Military Children and their Families • Military parents’ resilience and vulnerability affects the resilience and vulnerability of their children • Clinical experience suggests that children may be the most sensitive barometers of their family's adaptation • Each family brings its own capacities and liabilities to the coping process, and each has successive opportunities to adapt over the course of the deployment cycle and in the years after

12. Guard and Reserve Children Face Unique Challenges • Usually live far from military bases, treatment facilities or TRICARE providers • Often strangers to the institutions of military life • Many of these families did not think of themselves as “military” until plunged into the deployment cycle of our recent wars • Less likely to have the steady companionship of other military children or reliable access to military child or family programs

13. The Domains of Communities of Care • Communities of care improve access to information and support through concerted action across clinical and public health domains • Successful communities of care require innovative: • Policy • Practice

14. The Shift to TRICARE • The accelerated operational tempo in Afghanistan and Iraq drove a shift of military children out of care in military facilities and into civilian practices under TRICARE • Unfortunately, TRICARE doesn’t mandate “basic training” for providers so there is no guarantee that these providers understand military culture or deployment stress or their effects on military children • Nor is there a guarantee that enough pediatricians, child mental health professionals or family therapists will be available to meet the needs of military children wherever they reside • Guard and Reserve members, whose TRICARE benefits may be limited to the period immediately before, during, and after deployment, also face the difficult decision of whether to change pediatricians if their usual provider doesn’t accept TRICARE

15. Are Community Providers Prepared? • A recent survey of community providers (mental health and primary care combined) found that 56 percent don’t routinely ask patients about military service or military family status • http://www.mirecc.va.gov/docs/visn6/Serving_Those_Who_Have_Served.pdf • Few had served in the military or trained in DoD or VA health systems • Only 29 percent of community providers felt that they knew how to refer a veteran to VA care • How can we assist community providers and advocate for military families?

16. Envisioning Communities of Care • DoDhas tremendous capacity to support service members and their children through clinical and family services but there are limits … • Community response must be flexible enough to track military families and their children as they change over time • Military children don’t wear uniforms but they should not go unrecognized and unsupported in their communities

17. Obstacles to Building Communities of Care • Health-care providers are trained focus on discrete diseases but communities of care require a broader perspective • Many issues can affect families and children, creating a wide array of clinical and nonclinical needs

18. PTSD and Other Deployment Health Problems Coexist With and are Strongly Affected by Non-Clinical Issues • One of the most important predictors of whether combat veterans develop PTSD is their level of perceived social support from their families • Difficult economic times are likely to exacerbate their PTSD, depression, substance abuse, chronic pain or other health problems • PTSD or TBI may contribute to homelessness for veterans and their families • Even the best clinical practice guidelines for deployment health problems need to incorporate public health perspectives

19. The best arena for intervention is often the community rather than the clinic but how do we ensure that there is no wrong door to which service members and their families can  turn for the right help?  

20. Military Programs that Support Communities of Care • Family Readiness Groups (FRGs) connect families with their service member’s unit and with one another • The FRG is the commanders’ tool • Online virtual FRGs promote community support and continuity for geographically dispersed units

21. More Military Programs • Military OneSource • RealWarriors.Net • AfterDeployment.Org, offers links to information, support and clinical resources

22. Still More Military Programs • The Office of Deputy Assistant Secretary of Defense of Military Community and Family Programs coordinates Quality of Life Programs • The Defense Centers of Excellence (DCoE) for Psychological Health and TBI • Military Kids Connect

23. Families Overcoming Under Stress (FOCUS) • UCLA and the Harvard School of Medicine collaboration • A preventive intervention that teaches children and families to cope with difficulties • The Navy’s Bureau of Medicine and Surgery adopted FOCUS through a contract with UCLA in 2008

24. FOCUS as a Building Block of Communities of Care • Detect stress early and effectively promote family and community resilience • FOCUS uses the same principles in civilian communities (sometimes through online resources) • FOCUS is scalable and portable, and can be tailored

25. National Guard Programs • NG Family Assistance Centers open to all military families • Operation: Military Kids (OMK), a collaboration with communities to support National Guard and Reserve children affected by deployment

26. Military Partnerships • 4-H Clubs, a program of the US Department of Agriculture, partners with Army, Air Force, and Navy to support military children • Boy Scouts of Americaserves 19,750 military children annually on bases around the world

27. The National Resource Directory • Joint effort of Departments of Defense, Veterans Affairs and Labor to connects wounded warriors, service members, veterans, and their families and caregivers with helpful programs and services through a virtual community • NRD’s greatest weakness derives from its vast ambition • Practical solution modeled by WarWithin.org, a demonstration project of the Citizen Soldier Support Program • WarWithin.org – effective model of how to develop and maintain state-by-state content make the National Resource Directory more timely, accurate and useful

28. Civilian Responses that Support Communities of Care • The National Military Family Association (NMFA) and the Military Child Education Coalition (MCEC): excellent examples of civilian organizations that effectively mobilize civilian communities  • Zero to Three: develops high quality training and education to meet the needs of military families and infants • Give an Hour:organizes health professionals and others who volunteer free services to meet the mental health needs of service members and their families – including Community Blueprint

29. The Military Child Education Coalition (MCEC) • MCEC helps families, schools, and communities support military children throughout their academic careers • MCEC initiates innovation to advocate for military-connected kids – such as Living in the New Normal Institute (LINN-I)

30. Sesame Street’s Talk Listen Connect

31. New Partnerships to Build Communities of Care • Paving the Road Home, a program of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) • Policy Academies bring together state-level teams of community mental health and substance abuse service leaders, DoD and VA representatives, and veterans’ service organizations • Every US state and territory has attended at least one SAMHSA Policy Academy

32. Working State by State • The North Carolina Focus • Replication in Virginia and Beyond Working at the National Level • Joining Forces • Each of the Nation’s 152 VA Medical Centers will hold a Community Mental Health Summit before 9/15/2013

33. Next Steps: Evidence-Based, Effective Communities of Care • The first lesson: Identify military children • The second lesson: No single approach to serving our nation’s military • Look for synergy among multiple programs rather than choosing among approaches and services

34. Recommendations: From Clinical Programs to Communities of Care • Clinicians should ask, “Have you or someone close to you served in the military?” • Military history and military family status should be highlighted in each person’s medical record so that it is noted at each encounter • Incentivize military history taking to improve health outcomes and reduce healthcare costs • Teach all program staff about military culture and basic deployment mental health • Register the names of clinical programs that follow such guidelines in the National Resource Directory

35. Recommendations for Educational, Occupational, Congregational, Local Governmental and Other Community Settings • Note military connection in school records • Employers and EAPs note military-connected employees • Clergy leaders be aware of the presence and contributions of military families • State and local governments train on military • Campus faculty and staff build on best practices • All governments and communities commit to fully update the National Resource Directory • Librarians in all settings promote the National Resource Directory

36. Implementing Salmon’s Vision • PIE principles provide a strong foundation to build communities of care for military children • Focus on recognizing military children and addressing their problems in close proximity to their homes, schools, community organizations and doctor’s offices • Identify their needs with immediacy by watching for early warning signs of stress rather than waiting for the development of clinical disorders • Proceed with high expectancy that military children will continue to cope, grow, and succeed as valued citizens of their communities and their nation

37. There is Such a Thing as a Military Child • Military children and their families constitute one of the largest American subcultures yet they are also one of the least visible • These children are embedded in families and communities and in a military culture that values humility and self-sufficiency • They strive to put the needs of others (including their military parents) above their own

38. Effective Communities of Care • Measured by their public awareness of military children • The distinguished physician and medical educator Francis Peabody once said that “the secret of the care of the patient is caring about the patient” • The secret of creating communities of care for military children is creating communities that care about military children • This will require effort and time, but we believe it is an attainable goal.

39. Summary • Defining Communities of Care • History of a Public Health Perspective • Building Communities of Care for Military Children • Community of Care Domains • Programs that contribute to Communities of Care • Coordination and Recommendations • across states • throughout the Nation • For clinical, educational, and governmental impact

40. QUESTIONS? Harold Kudler, MD: Harold.Kudler@va.gov Rebecca Porter, PhD: rebecca.i.porter2.mil@mail.mil