VA Puget Sound Health Care System

Innovations in Health Care of OIF/OEF Veterans

OutreachService Delivery ModelTreatment Approaches

Research

Joint VA/DoD Task Force RecommendationsAdopt a Public Health Approach

Proactive case-finding through outreach

Education of unit commanders, family, employers

Early detection and intervention through screening

Inter-agency partnerships and sharing agreements

Seamless transition from DoD to VA and Vet Center Reduce stigma by emphasizing “normalizing”

readjustment problems Primary care-based service delivery of mental health Expectations for wellness, recovery, resilience, &

rehabilitation Facilitate vocational rehabilitation and job re-entry

Outreach

Inter-agency Collaboration

I. Northwest Network Deployment Health SummitRegional Conference Nov. 8-9, 2004

• 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)

I. Northwest Network Deployment Health Summit 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

I. Northwest Network Deployment Health Summit Follow-Up Monitoring of Progress

• Publication of Summit proceedings (contact info, action plan, resource lists, etc.)

• Jointly Organized and Attended Regional Training Conferences for VA, DoD, and community

• Monthly planning meetings of inter-agency partners

• 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

II. Interagency Memo of AgreementPurpose

• Formal interagency agreement (MOA) 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 and WA National Guard

• Commitment to provide customer service, not just briefings, 3-6 months following deployment.

II. 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

II. Memo of AgreementResponsibilities

• Directive to National Guard and reserve unit commanders by the Adjutant General

• 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

II. Memo of AgreementService Delivery Outcomes from Outreach

• 31 total FAD/PDHRA events for 42 units (2005 thru May

2007)

• Average 18 volunteers per event

• Total participants at FAD events = 2,900

• Outcomes from the FAD events for participants:– Mental health referrals made to 41%

– On-site enrollment in VHA health care for 50%

– On-site filing of claims for compensation for 18%

– On-site employment assistance provided to 24%

– TriCare briefings to 91%

Service Delivery Model

VA PSHCS Mental Health Services for OIF/OEF Veterans Organizational Diagram

Vet CentersSeattleTacoma

BellinghamYakima

Spokane

VA PTSD ProgramsPTSD Clinical Teams

women's' Trauma TeamPTSD Inpatient UnitPTSD Domiciliary

State Dept. Veterans Affairs29 contract therapists

Affiliated Mental Health Programs

Addictions ProgramsGeneral Mental Health

Post-Deployment ClinicPrimary medical care

Mental health screening/triage

Poly-Trauma ClinicTBI assessment &

Rehabilitation

Collaborative and Coordinated Care

PTSD ProgramsPTSD Programs

CenterCenterForFor

PolytraumaPolytraumaCareCare

Deployment Health Deployment Health ClinicClinic

• Integrated mental health and medical care• Preventive/health promotion based care• Family involvement in care• Brief CBT interventions• Case management• Disability benefits• Vocational rehabilitation consultation• Referrals to inpatient/outpatient mental health

services (PTSD, substance abuse, general mental health services) or specialty medical clinics within the VA Medical System

Deployment Health Clinic Integrated Care for Combat Veterans

Deployment Health Clinic StaffingSeattle Division

• Two 0.5 FTEE Primary Care Physicians• 0.5 FTEE ARNP• Clinical Psychologist

» Postdoctoral Fellow» Psychology Intern

• Mental health counselor• 0.5 FTEE Psychiatrist• 1.0 MSW• Vocational Rehabilitation Specialist

Improved Access to CareAdditional Strategies

Improve access to care (after hours clinics, telemedicine)

Deploy prescribers to Vet Centers with TM follow-up

Focus on spectrum of deployment-related readjustment

problems & mental disorders, not just PTSD

Use a “stepped-care” approach (start with education &

skills building)

Health promotion (tobacco, inactivity, obesity, etc.)

“Fast track” emergency bed on PTSD Inpatient Unit

Assess and accommodate patient preferences for

treatment

Patient Preferences Setting of Care

Clinic Setting Percent

Deployment Clinic 74%

Specialty Mental Health Clinic 11%

Primary Care Setting 6%

Patient Preferences Types of Service

Intervention

Prefer

(Do Not Prefer)

Employment, housing, finances 32 (46)%

Counseling for symptoms 38 (33)%

Medications 42(36)%

Treatment PreferencesModes of Counseling Delivery

Modes of Delivery Prefer (Do Not Prefer)

Individual sessions by Telephone 12 (72)%Face-to-face individual sessions 44 (22)%Group sessions 10 (76)%Couples or family sessions 12 (63)%More likely to attend sessions if early morning or evening availability (yes/no)

61%

Would like to use e-mail to stay in touch with counselor (yes/no)

63%

Patient Preferences Types of Counseling

InterventionPrefer

(Do Not Prefer)

Talking about combat experiences 33 (43)%

Talking about how I think and feel now without going into combat experiences

43 (27)%

Practical advice to solve current problems 50 (19)%

Engaging in activities that will improve my feelings 46 (18)%

Improving how I related to others and communicate

46 (20)%

Learn skills for calming down and reducing stress 55 (16)%

Learning how to take better care of my physical health (e.g., losing weight, stopping smoking, etc.)

49 (33)%

Special Clinical Emphasis AreasQuality Improvement Needs Assessment (N = 420)

Measure

PTSD

(%)

No PTSD

(%)

OR

(95% CI)

Problematic ETOH use 21.4 6.5 3.9

(1.7-9.0)

Problematic drug use 3.1 1.9 ns

Current smoking 32.0 22.4 ns

Exercise deficient 82.1 49.5 4.69

(2.8-8.0)

Special Clinical Emphasis AreasQuality Improvement Needs Assessment (N = 420)

Measure

PTSD

(%)

No PTSD

(%)

OR

(95% CI)

Suicide risk 21.2 0.9 28.2

(3.8 – 208.8)

Attempted suicide last 4 months

4.1 0.9 ns

Special Clinical Emphasis AreasQuality Improvement Needs Assessment (N = 420)

Measure

PTSD

(%)

No PTSD

(%)

OR

(95% CI)

severe pain 24.5 8.3% 3.6

(1.8-7.3)

poor physical health 23.0 3.7 7.7

(2.7-22.1)

poor sleep 80.3% 33.2% 14.9

(8.6-25.6)

Special Clinical Emphasis AreasQuality Improvement Needs Assessment (N = 420)

Measure PTSD

(%)

No PTSD

(%)

OR

(95% CI)

Verbally abusive last 4 months

62.8 18.6 7.4

(4.1-13.4)

Destroyed Property last 4 months

25.4 6.2 5.2

(2.1-12.6)

Threatened someone with violence last 4 months

33.0 7.2 6.3

(2.7-14.5)

Had a physical fight last 4 months

15.5 4.1 4.3

(1.5-12.5)

Thoughts of hurting someone last 4 months

62.8 14.4 10.0

(5.3-18.9)

Research

I. Prazosin for PTSD

Prazosin for PTSD-Related Nightmares

• Blockade of CNS alpha-1 adrenergic receptors with a lipid soluble antagonist will reduce nighttime PTSD symptoms.

• Prazosin is the only lipid soluble alpha-1 AR antagonist; thus, the only one that easily enters the brain.

First Efficacy Demonstration:Prazosin vs. Placebo Crossover Study

• 10 Vietnam combat veterans (age = 53 ± 3 years) randomized to:

– placebo followed by prazosin (n = 5)

– prazosin followed by placebo (n = 5)

• Titration schedule:– 1 mg q.h.s. x 3 nights, 2 mg x 4 nights, 4 mg x 7 nights, 6 mg x 7

nights, 10 mg for 6 weeks

Prazosin Placebo p value

CAPS Distressing Dreams

baselineendpoint

6.9 ± 0.93.6 ± 2.6

7.1 ± 0.96.7 ± 1.6

< 0.001

CAPS Difficulty Sleeping

baselineendpoint

7.4 ± 1.3 4.0 ± 2.3

7.3 ± 0.97.1 ± 1.9

< 0.01

Total CAPS

baselineendpoint

79.1 ± 17.057.3 ± 11.4

83.6 ± 17.686.5 ± 30.0

< 0.01

CGIC

endpoint 2.0 ± 0.5 4.5 ± 1.8 < 0.01

Results: Primary Outcome Measures

Raskind, MA et al., Am J Psychiatry 160:371-373, 2003.

Clinical Global Impression of Change for Overall PTSD Symptoms

markedly improved

moderately improved

minimally improved

no change

minimally worse

moderately worse

markedly worse

1

2

3

4

5

6

7

Placebo

Prazosin

Second Efficacy Demonstration:Prazosin vs. Placebo Parallel Group Study

*p<0.01, **p<0.001

Outcome MeasurePrazosin(n = 17)

Placebo(n = 17)

statistic (change scores)

Effect Size (Cohen's d)

CAPS Distressing DreamsBaselineEndpoint

6.5 1.02.9 2.7

6.1 1.05.2 2.2 t = 2.48* 0.9

PSQIBaselineEndpoint

13.5 4.29.7 3.9

13.4 2.712.6 4.1 t = 2.82* 0.7

CGIC (endpoint) 2.3 1.0 3.7 1.2 t = 3.56** 1.3

CGIC – proportion moderately or markedly improved

12/17 2/17 Fisher’s Exact p<0.001** N/A

Raskind et al. Biol. Psychiatry 2007; 61: 928-934Raskind et al. Biol. Psychiatry 2007; 61: 928-934

II. Behavioral Activation

Alternative PsychotherapiesContraindications for Evidence-Based PTSD Approaches

• Most OIF/OEF VA patients with mental disorders don’t have PTSD.

• Difficulty engaging OIF/OEF patients in traditional psychotherapy (e.g., high no show rates).

• Prevalence of TBI and other comorbidities may contraindicate emotionally evocative therapies.

• Higher dropout rates with exposure therapy.

• Reluctance of therapists/patients to revivify trauma memories.

• Comparative trials show evidence-based therapies work about equally well.

Behavioral Activation

Present centered, “outside in” behavioral approach that targets: avoidance and restricted range of behavior diminished rewards

ruminative thinking

disruption of normal routines

Identify and engage in reinforcing activities consistent with long-term goals and values.

In vivo exposure through graded task assignments that facilitate mastery through re-engagement in formerly pleasurable activities.

Results from homework monitoring of activities and mood reviewed in therapy to establish linkage between actions and emotional states.

Easy to implement and highly acceptable to patients.

Rates of Response and Remission (BDI): High Severity Subgroup

Note: Total bar represents response; lower bar represents remission

52%40%44%

24%

5% 8%

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

ADM CT BA

Pat

ien

ts (

%)

49%

76%

48%

BA for Treatment of PTSD

Open trial of 11 PTSD patients1

• Mean symptom reduction on CAPS = 12 points

• Five of 11 veterans showed statistically reliable change

• 4 of 11 veterans lost diagnosis of PTSD

Jackupak, Robeerts, Maerrtell, Mulick, Michael, Reed, Balsam, Yoshimoto, McFall. A pilot study of behavioral activation for veterans with PTSD. J Trauma Stress 2006; 19: 387-391.

III. Integrated Care:Health Promotion in PTSD

Rationale for Integrating Health Promotion Into Post-Deployment Mental Health Care

• Providers have advanced training in treating behavioral and substance use disorders applicable to nicotine dependence

• Positioned to tailor cessation treatment to address the dynamic interaction of tobacco use with psychiatric symptoms

• The frequent, continuous nature of mental health care naturally promotes ongoing monitoring of smoking status and reapplication of treatment to encourage “recycling”

• Mental health clinics expand access to smoking cessation treatment for otherwise underserved veterans and overcome logistical barriers to care

Integrated Care versus the Usual Standard of VA Care for Smoking Cessation in PTSD

A Randomized Clinical Trial

McFall, M., et al. Improving Smoking Quit Rates for Patients with PTSD. Am J. Psychiatry 162:1311-1319

Objective

To compare the effectiveness of brief Integrated Care (IC) versus VA’s Usual Standard of Care (USC) for nicotine dependence in veterans undergoing mental health treatment for PTSD.

Integrated Care: Overview of Clinical Intervention

• Behavioral Counselinga

• Pharmacotherapy

• Self-help readings

• Relapse prevention/recovery and maintenance

____________a Six weekly sessions (20 minutes each) plus discretionary follow-up visits.

Clinical Outcomes:7-Day Point Prevalence for Non-Smoking Status (n=66)

0

5

10

15

20

25

30

35

40

45

2 mos. 4 mos. 6 mos. 9 mos.

IC

USC

GEE Analysis Results: Odds Ratio = 5.23, p < .0014

Assessment Period

% n

on-

smo

ker

Practice-Based IC for Smoking Cessation:

An Open Clinical Trial

McFall, M. et al. Integrating Tobacco Cessation Treatment into Mental Health Care for PTSD. American Journal of Addictions 2006; 15: 336-344.

7-Day Point Prevalence Abstinence and Percent Reduction for Continued Smokers (n = 107)

0

5

10

15

20

25

30

35

40

2 mos. 4 mos. 6 mos. 9 mos.

Abstinent

Reduced

Assessment Period

Pe

rce

nt

Conclusions from Preliminary Work

• It is feasible to incorporate guideline-based smoking cessation treatment into routine delivery of mental health care for PTSD

• Integrating treatment of nicotine dependence is more effective than the usual standard of VA care within the VAPSHCS, for PTSD patients

• IC was a better vehicle than USC for for delivering cessation treatments of sufficient intensity, which may explain the superior results of IC

•Network Director•Facility Director•Service Lines

•VA & State DVA•Vet Centers•DoD (Military Director)•Dept. of Labor

•Seamless Transition to MTF•Vet Center & VA Outreach•Drill Weekends

•Deployment Health Clinic•SCI and RMS•Poly Trauma Program

•PTSD Inpatient and Outpatient programs•Addictions programs•Voc Rehab Services

•Resources•Organization•Mission priority

•Sharing agreements•Cross referral•Educational meetings

•Family Activity Day•PDHRA screening•Educational resources

•Uncomplicated mental disorders•Screening, education, brief supportive Rx•Triage to Mental Health

•Complicated/Severe cases•Patients who “accept” a PTSD Diagnosis•Specialized interventions

Mental Health

Primary Care

Specialty Medicine

Community Outreach

Case Finding

Interagency Collaboration

Administrative Infrastructure

Partners Function

Extras

Prevalence of PTSDStringently Defined

Population Prevalence

Viet Nam Veterans 9 – 15%

(20% – 30% lifetime)

Persian Gulf War Veterans 2 – 10%

Afghanistan Active Duty 6.2%

Iraq Active Duty 12.6%

US General Population 5% males (lifetime)

10.4% females (lifetime)

Distressing Mental Health Symptoms Liberal Screening Criteria

(Iraq Vets)Disorder(s) Screening at

DemobilizationDelayed

Screening

PTSD 9.8% 18.9% - 34.6%

Depression 4.5% 15.2% - 30%

PTSD, depression, or GAD

19.1% 28.5% - 40%

Barriers to Mental Health CareVAPSHCS Deployment Clinic Sample (N = 235)

Barrier % Agree

Difficulty scheduling an appointment 17

Difficult getting time off work 20

Concerned about financial costs of Rx 38

It might harm my career 21

Co-workers have less confidence in me 23

My employer would treat me differently 24

I would be seen as weak by others 28

I would feel weak or down on myself 13

Barriers to Mental Health CareVAPSHCS Deployment Clinic Sample (N = 235)

Barrier % Agree

Don’t want to be prescribed medications 24

Don’t think MH treatment will help me 9

Visits with MH professional not confidential 10

Don’t want to talk about upsetting war events 12