Transcript 7-Day Point Prevalence Rates

Northwest Network
Post-Deployment Health Service Delivery Model
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Components of An Effective System of Care
1.
2.
3.
4.
Administrative Infrastructure
Interagency Collaboration and Sharing Agreements
Coordinated Outreach Activities
Integrated System of Care:
-Primary Care vs. Specialty Mental Health Care
-VAMC-Based Care vs. Community Care
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Administrative Infrastructure
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Partners
Function
•PTSD Inpatient and Outpatient programs
•Addictions programs
•General Mental Health
•Voc Rehab Services
•Deployment Health Clinic
•Spinal Cord Injury and RMS
Mental
Health
•Complicated/Severe cases
•Patients who “accept” a PTSD Diagnosis
•Specialized interventions
Primary Care
•Uncomplicated cases
•Screening, education, brief supportive Rx
•Triage to Mental Health
Specialty Medicine
•Seamless Transition Program
•Vet Center & VA Outreach
•Drill Weekends for Reserve Units
•VA & WA State DVA
•Vet Centers
•DoD
•Dept. of Labor
•Network
•Facility
•MH Service
•Military Director
•Federal & State
Community Outreach
Case Finding
Interagency Collaboration
Administrative Infrastructure
•Primary Care Screen
•Family Activity Day
•DoD screening
•Educational resources
•Sharing agreements
•Cross referral
•Educational meetings
•Resources
•Organization
•Mission priority
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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
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Examples of System Building
1. Northwest Network Deployment Health Summit
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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)
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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
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DOD and Washington National Guard
Unit Locations Statewide
BELLINGHAM
C/898 EN
ANACORTES
C/898 EN
OKANOGAN
SPOKANE /
FAIRCHILD AFB
EVERETT
HHC 898 EN
215TH EIS
SNOHOMISH
A/898 EN
POULSBO
REDMOND
1-205th Reg (Ldr)
BREMERTON
KENT
B/303 AR
HHC 1-303 AR
A/B/161 IN
281 MI
PORT ORCHARD
B/303 AR
248 RAOC
81 HQ
HHC/A/C/181 BN
143RD CBCS
262nd IWAS
116TH WF
WENATCHEE
C/1-161 IN
TACOMA
EPHRATA
Trp Cmd
341 MI
Cheney
1161 TC
256th CBSC
E/303 CAV
SHELTON
OLYMPIA
HHB 2-146 FA
A/2-146 FA
CENTRALIA
A/2-146 FA
McChord AFB
SEATTLE
PUYALLUP
MONTESANO
141 AW
242 CBSC
HHC/C 1-161 IN
B/2-146 FA
B/1-303 AR
66th Avn BDE
341st MI
A/1-19 SF
791st Chem
FORT LEWIS
81 REAR DET
66th Avn BDE
E/168 AV
B/14 EN
A/1-19 SF
CAMP MURRAY – JFHQ
122 MPAD
SOD PAC
I/O GP
1-205th Reg (Ldr)
111th ASOS’s
116th ASOC
173rd MDF
252nd Group
254th Red Horse
LONGVIEW
MOSES LAKE
BUCKLEY
ELLENSBURG
YAKIMA
B/181 BN
420 Chem BN
792 Chem Co
144th ARFOR
1-205th Reg (Ldr)
PULLMAN
B 2-146 FA
TOPPENISH
HHC/1-161 IN
CLARKSTON
PASCO
A/1-303 AR
GRANDVIEW
791st Chem Co
C/2-146 FA
C/1-161 IN
116 RAOC
WALLA WALLA
A/1-303 AR
VANCOUVER
C/2-146 FA
792nd Chem
A/1-19 SF
CAMAS
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VAMC, Vet Centers, WDVA PTSD Program, WANG Family Support Sites
Whatcom
San Juan
Pend
Oreille
Ferry
Okanogan
Stevens
Skagit
Island
Clallam
Snohomish
Chelan
Jefferson
Kitsap
Grays
Harbor
9 King County
PTSD Contractors
Kittitas
Pierce
Thurston
Lewis
Adams
Grant
Whitman
Franklin
Yakima
Garfield
Columbia
Wahkiakum
Cowlitz
VAMC
Spokane
Lincoln
King
Mason
Pacific
Douglas
Clark
RCS Vet Center
VA Community Based Clinic Site
Benton
Skamania
Walla Walla
Asotin
Klickitat
Joint WDVA and Vet Center Contractor
WDVA PTSD Outpatient Contractor Site
WDVA PTSD Program Outpatient Remote Site
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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)
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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
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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 communitybased PTSD contract providers
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Interagency Collaboration and
Sharing Agreements
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1. Interagency Memo of Agreement
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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.
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Memo of Agreement (Cont’d)
Participating Partners
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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
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Washington State MOU
MOU PARTICIPANTS
WA Military Department
WA Dept of VEterans Affairs
Employment Security Department
Employer Support of Guard & Reserves
Dept of Labor-VETS
VA Veterans Benefits Administration
National Guard
VA Veterans Health Administration
Reserves
Veterans Service Organizations
Tom Riggs
MOU Coordinator
(360) 586-1091
SRP
Reunion
Training
Freedom
Salute
Family Day
Volunteer
Training
(Annual Event)
Adopt An
Armory
VSO
WDVA
Tom Scumacher
WDVA
VHA
Tom Scumacher
WDVA
Colleen Gilbert
WDVA
VBA
Debbie Allen
National Guard
National Guard
Family Assistance
Centers
ESD
VBA
DOL-VETS
VHA
VHA
2 individuals per element
ESD
VSO
Local Post-Chapter
ESGR
VSO
2 individuals per element
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Coordinated Outreach Activities
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1. MOU-Driven Outreach Plan and Responsibilities
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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
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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
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Service Delivery Outcomes
Family Activity Day Events
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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%)
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Health Screening and Triage at FAD
• PDHRA Administration
• Automated Scoring with Instant Feedback
• On-Site “Second Tier” Screening and Triage
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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%
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2. Seamless Transition Program at MAMC
(Total VA health care referrals = 3,156 [Sept-03 – 7-Apr-06])
Seamless Transition Referrals
NNMC - Bethesda
14%
Brooke AMC
6%
6%
Darnell - Fort Hood
0%
9%
Eisenhower
5%
Evans - Fort Carson
9%
Madigan
Camp Pendleton
51%
Walter Reed Medical
Center
Current Number and Percentage of Total Referrals to Date by Facility
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3. Other Outreach Activities (Cont’d)
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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
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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
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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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Integrated System of Care
Reorganize Existing Programs
Develop Innovative Programs
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Reorganize Existing Programs
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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)
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PTSD Specialty Services
• PTSD Outpatient Clinic
• PTSD Inpatient Evaluation and Brief
Treatment Unit
• PTSD Domiciliary
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PTSD Outpatient Clinic
Seattle VA Medical Center
Post-Deployment Readjustment Class
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Table of Contents
How to Use this Manual--------------------------------------------------------------------2
Topics
Class Introduction (2 sessions)------------------------------------------------------3
Medications (1 session)------------------------------------------------------------7
Goal Setting (1 session)------------------------------------------------------------9
Health and Wellness (1 session, plus one optional session)-----------------13
Sleep Hygiene (1 session)---------------------------------------------------------19
Mood Management (2 sessions)-------------------------------------------------24
Anger Management (2 sessions)-------------------------------------------------31
Relationships (1 session) ---------------------------------------------------------37
Graduation (1 session)-----------------------------------------------------------------41
Handouts
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The PTSD Evaluation/Brief Treatment Unit
Puget Sound Health Care System
Benefits and Challenges of Integrating
OEF/OIF Veterans into Existing Mental
Health Treatment Programs
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Operational Characteristics
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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)
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Commonalities
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Nature of combat experiences
» combatants not immediately identifiable
» Guerilla tactics
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Sociopolitical context of wars
» Divisions in public attitudes toward war
» Changing timelines and goals of military efforts
» Marked Cultural/Ideological/Religious differences
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Media coverage
» Public access to images of war
» Scandals involving war crimes
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Differences
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Volunteer/Career Military
» Broader range of ages, education, SES, previous training, gender
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Media/Communications
» Significantly less delay in reporting
» Email, telecommunication options
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Symptom profiles
» Acute re-experiencing and hyperarousal symptoms, less entrenched
avoidance behaviors
» novelty of symptoms with recent recall of premorbid functioning
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Challenges to Integrated Treatment
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Differences in experiences, life stage, and duration of
symptoms
» Can interfere with group cohesion
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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
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Benefits of Integrated Treatment
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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)
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Differences in Treatment Approaches
for OIF/OEF Veterans
Prioritizing most immediate/current issues
Stabilization
of Acute Psychiatric Symptoms
Occupational
Relational
Substance
and financial functioning
functioning (divorce, infidelity, domestic violence)
abuse issues; legal issues
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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).
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Develop Innovative Clinical Programs
1. Deployment Health Clinic
2. Level II Polytrauma Center
3. Telephone-based tobacco cessation intervention
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VA PSHCS Mental Health Services for OIF/OEF Veterans
Organizational Diagram
Vet Centers
Seattle
Tacoma
Bellingham
Yakima
Spokane
VA PTSD Programs
PTSD Clinical Teams
Women’s Trauma Team
PTSD Inpatient Unit
PTSD Domiciliary
Post-Deployment Clinic
Primary medical care
Mental health screening/triage
Brief therapy & meds management
Affiliated Mental Health Programs
Addictions Programs
General Mental Health
State Dept. Veterans Affairs
29 contract therapists
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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
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Facility and Network OIF/OEF Workload Data
FY02 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)
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