Cover Slide Title

1
VA Update on Psychological Health and TBI
Clinical Initiatives
Sonja V. Batten, Ph.D. Acting Deputy
Director Defense Centers of Excellence
for Psychological Health and TBI
November, 2008
2
Acknowledgements

• VACO OMHS
• VACO Rehabilitation Services
• Han Kang

3
Current DoD Roster of Recent War Veterans

• Over 1.6 million service members have served in
  OEF/OIF to date
• Latest Update of roster for veterans
• Provided to Dr. Kang, Veterans Health
  Administration (VHA) Environmental Epidemiology
  Service, on May 2, 2008
• Qualifications of DoDs OEF/OIF deployment roster
• Contains list of veterans who have left active
  duty and does not include currently serving
  active duty personnel
• Does not distinguish OEF from OIF veterans
• Roster only includes separated OEF/OIF veterans
  with out-of-theater dates through February 2008
• 4,271 veterans who died in-theater are not
  included

4
Updated Roster of OIF and OEF Veterans Who Have
Left Active Duty

• 868,717 OEF and OIF veterans who have left
  active duty and become eligible for VA health
  care since FY 2002
• 50 (437,873) Former Active Duty troops
• 50 (430,844) Reserve and National Guard
  

5
VA Health Care Utilization for FY 2002-2008 (2nd
QT) by Service Component

• Among all 868,717 separated OEF/OIF Veterans
• 40 (347,750) of total separated OEF/OIF veterans
  have obtained VA health care since FY 2002
  (cumulative total)
• 437,873 Former Active Duty Troops
• 41 (179,475) have sought VA health care since
  FY 2002 (cumulative total)
• 430,844 Reserve/National Guard Members
• 39 (168,275) have sought VA health care since
  FY 2002 (cumulative total)

6
Comparison of VA Health Care Requirements

• The cumulative total of 347,750 OEF/OIF veterans
  evaluated by VA over approximately 6 years from
  FY 2002 through FY 2008 (2nd QT) represents about
  6 of the 5.5 million individuals who received
  VHA health care in any one year (total VHA
  patient population of 5.5 million in 2007).

7
Demographic Characteristics of OEF and OIF
Veterans Utilizing VA Health Care

• OEF/OIF
  Veterans
• 
  (n 347,750)
• Sex
• Male
  88
• Female 12
  
• Age Group
• lt20 7
  
• 20-29 51
  
• 30-39 23
  
• 40 18
  
• Branch
• Air Force
  12
• Army 64
  
• Marine 13
  
• Navy
  11
• Unit Type
• Active 52
  
• Reserve/Guard
  48
  
• Rank

8
Frequency of Possible Diagnoses Among OEF and
OIF Veterans

• Diagnosis (n 347,750)
• (Broad ICD-9 Categories)
  
  Frequency
•  
• Infectious and Parasitic Diseases
  (001-139) 40,956 11.8
• Malignant Neoplasms (140-208)
  3,248 0.9
• Benign Neoplasms (210-239)
  13,910
  4.0
• Diseases of Endocrine/Nutritional/ Metabolic
  Systems (240-279)
  75,850 21.8
• Diseases of Blood and Blood Forming Organs
  (280-289) 7,675 2.2
• Mental Disorders (290-319)
  
  147,744 42.5
• Diseases of Nervous System/ Sense Organs
  (320-389)
  121,473 34.9
• Diseases of Circulatory System (390-459)
  
  56,900 16.4
• Disease of Respiratory System (460-519)
  
  71,087 20.4
• Disease of Digestive System (520-579)
  
  110,449 31.8
• Diseases of Genitourinary System (580-629)
  
  37,118 10.7
• Diseases of Skin (680-709) 55,797
  16.0
• Diseases of Musculoskeletal System/Connective
  System (710-739) 165,439
  47.6
• Symptoms, Signs and Ill Defined Conditions
  (780-799)
  138,043 39.7
• Injury/Poisonings (800-999)
  
  73,767 21.2
•  

9
Frequency of Possible Mental Disorders Among
OEF/OIF Veterans since 2002

•  
• Disease Category (ICD 290-319 code)
  Total Number of GWOT
  Veterans
• PTSD (ICD-9CM 309.81)
  75,719
• Depressive Disorders (311)
  50,732
• Neurotic Disorders (300) 40,157
  
• Affective Psychoses (296) 28,734
• Nondependent Abuse of Drugs (ICD 305)
  21,201
• Alcohol Dependence Syndrome (303) 12,780
• Special Symptoms, Not Elsewhere Classified (307)
  7,685
• Sexual Deviations and Disorders (302) 7,076
• Drug Dependence (304) 5,764
• Specific Nonpsychotic Mental Disorder 4,654
• due to Organic Brain Damage (310)
• Note These are cumulative data since FY
  2002. ICD diagnoses used in these analyses are
  obtained from computerized administrative data.
  Although diagnoses are made by trained healthcare
  providers, up to one-third of coded diagnoses may
  not be confirmed when initially coded because the
  diagnosis is rule-out or provisional, pending
  further evaluation.
• A total of 147,744 unique patients received a
  diagnosis of a possible mental disorder. A
  veteran may have more than one mental disorder
  diagnosis and each diagnosis is entered
  separately in this table therefore, the total
  number above will be higher than 147,744.
• This row of data does not include
  information on PTSD from VAs Vet Centers or data
  from veterans not enrolled for VHA health care.
  Also, this row does not include veterans who did
  not receive a diagnosis of PTSD (ICD 309.81) but
  had a diagnosis of adjustment reaction (ICD-9
  309).
• This category currently excludes
  39,811veterans who have a diagnosis of tobacco
  use disorder (ICD-9CM 305.1) and no other ICD-9CM
  305 diagnoses.

10
Mental Health Services in VA Initiatives and
Current Status
11
MH Strategic PlanAdopted 2004

• Implement Presidents New Freedom Commission on
  MH Report within VA
• Principal components
• Expanding access and capacity
• Integrating MH and primary care
• Transforming system to focus on recovery
  rehabilitation
• Implementing evidence-based care
• Returning veterans
• Suicide Prevention

12
MHSP Implementation

• Over 850 million invested since FY05 in specific
  Mental Health Enhancement Initiatives (MHEI)
• Increasing basic MH funding, e.g., over 3.2
  billion total for mental health services in FY08
• Over 530 million in proposed VA MHEI budget for
  FY09 and over 3.8 billion in basic funding
• Over 3,900 new mental health staff hired since FY
  2005 total mental health staff in the system
  almost 17,000

13
Basic Mental Health Programming

• Programs available before Mental Health
  Initiatives have stayed the same or grown in
  capacity
• Outpatient specialty mental health clinics
• Inpatient psychiatry programs
• Residential Rehabilitation treatment programs
• Substance Use Disorder care
• Vocational Rehabilitation
• Specialty PTSD programs
• Local initiatives
• Programs that have declined
• Day Hospital
• Sheltered Workshop

14
PTSD and OEF/OIF Programs

• Expanded PTSD points of care
• PTSD Mentoring program
• SeRV-MH teams for returning OEF/OIF veterans
• 95 teams

15
VA Dissemination of ESTs

• Passive dissemination of guidelines (e.g.,
  printing guidelines) is often ineffective
• Three current VA dissemination initiatives (2
  more planned)
• Prolonged Exposure for PTSD
• Cognitive Processing Therapy for PTSD
• Acceptance and Commitment Therapy for Depression
  and Associated Anxiety Symptoms
• OMHS leadership supports need to train clinicians
  AND develop internal resources to continue
  training over time
• Self-sustaining

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Addressing Barriers Building Practitioner Support

• Dissemination is unlikely to succeed if changes
  are only initiated top down
• Problems with previous efforts at dissemination
  may have been their unidirectional nature
• Emphasis on changing practitioner behavior as
  decided by researchers or administrators

17
Addressing Barriers Training

• Training/Supervision designed to remedy skills
  deficits and attitudinal obstacles
• Training will be adequate in intensity
• Training will include effective change methods
  (e.g., modeling, role play, feedback, homework)
• Trainees will see two cases under weekly
  supervision
• Trainees will commit to use the therapy in which
  they are trained, supervise others

18
Enhanced Access and Continuity of Care

• 24/14 requirement for new mental health referrals
• Expanded clinic hours
• Required follow-up of missed appointments
• Requirement for MH in Emergency Departments and
  Urgent Care Centers

19
Military Sexual Trauma

• MST Coordinator in every VA facility
• National MST Recovery Team provides education
  and mentoring to MST coordinators and providers
  nation-wide

20
Centers of Excellence

• 10 MIRECCs
• National Center for PTSD
• 3 Congressionally-mandated COEs for mental health
  (Canandaigua COE with suicide prevention focus is
  one)
• VA collaboration with Defense Centers of
  Excellence for Psychological Health and TBI

21
Suicide Prevention

• Suicide Prevention Coordinator in each medical
  center
• Centers of Excellence
• National programs for education and awareness
• 24/7 Hotline, in conjunction with SAMHSA suicide
  prevention hotline number
• 1-800-273-TALK
• Option directs Veterans to a VA professional with
  access to Electronic Medical Record
• Hand-off to local Suicide Prevention Coordinator
  for follow-up and ongoing care

22
Mental Health Services in Polytrauma

• MH team in every Level 1 Polytrauma Center
• MH staff on VISN level Polytrauma teams
• MH staff in Transitional Living programs for
  Polytrauma patients

23
VAs Polytrauma System of Care TBI Screening
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Polytrauma

• Two or more injuries to physical regions or
  organ systems, one of which may be life
  threatening, resulting in physical, cognitive,
  psychological, or psychosocial impairments and
  functional disability.
• TBI frequently occurs in polytrauma in
  combination with other disabling conditions
  (e.g., amputation, auditory and visual
  impairments, SCI, PTSD, other MH conditions).
• Brain injury is the impairment that primarily
  guides the course of the rehabilitation.
• VHA Handbook 1172.1

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VA Polytrauma System of Care

• Integrated system of care with over 100
  specialized rehabilitation sites distributed
  across the country
• Services delivered by interdisciplinary teams of
  rehabilitation specialists and medical
  consultants
• Brain injury drives the care
• Advanced rehabilitation practices and equipment
  with focus on independence and community
  re-integration
• Emphasis on care coordination and case management
• Provide life-long care and access to a continuum
  of services
• Polytrauma Telehealth Network

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Implementation of the VA Polytrauma System of Care
April 07 TBI Screening
March 07 80 Polytrauma Support Clinic Teams,
50 Polytrauma Points of Contact
July 06 Polytrauma Telehealth Network
December 05 22 Polytrauma Network Sites
February 05 Four Polytrauma Rehabilitation
Centers
1992 VHA TBI Lead Centers Selected
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PSC Components
Polytrauma Centers (4) Regional referral centers
Goal Get Home
Polytrauma Network Sites (22) VISN level referral
sites
Polytrauma Support Clinics (80) Facility level
teams
Polytrauma Points of Contact (50) Referral and
care coordination
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Polytrauma Rehabilitation Centers
Richmond
Tampa
Palo Alto
Minneapolis
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Polytrauma Rehabilitation Centers

• Regional referral centers for veterans and active
  duty service members with TBI and polytrauma
• Patients with high degree of medical complexity
  and varied patterns of disabling injuries
• Full range of acute comprehensive medical and
  rehabilitative services
• Comprehensive acute interdisciplinary inpatient
  rehabilitation
• Comprehensive interdisciplinary inpatient
  evaluations
• Emerging Consciousness Program
• Residential Transitional Rehabilitation Program
• Leadership in education, research and program
  development

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Polytrauma Network Sites

• One PNS located in each VISN ( San Juan)
• Interdisciplinary, specialized post-acute
  rehabilitative services (inpatient and
  outpatient)
• Develop and manage rehabilitation plans for
  veterans and active duty service members with TBI
  and polytrauma
• Serve as resources and coordinate services for
  TBI and polytrauma across the VISN
• Develop and conduct VISN level educational
  programs for providers as well as patients and
  families in the areas of polytrauma and TBI
• Provide leadership for tracking VISN level
  outcome data and performance monitors for
  polytrauma and TBI.

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Role of the Polytrauma Support Clinical Team

• Located at 80 VAMCs across VHA
• Primary role
• Specialty rehabilitation care closer to home
• Evaluation, development of a treatment plan,
  interdisciplinary rehabilitation care, and
  long-term management of patients with on-going or
  changed rehabilitation needs
• Nursing and social work care managers coordinate
  clinical and support services for patients and
  their families
• Lead role
• Conduct comprehensive evaluations of patients
  with positive TBI screens and develop
  rehabilitation and community re-integration plans

32
Polytrauma Points of Contact

• Designated in March, 2007 at 50 Medical Centers
  without specialized rehabilitation teams
• VA staff member knowledgeable of Polytrauma
  System of Care
• Case management and referral to Polytrauma System
  of Care
• Community Based Outpatient Clinic
• VA contact close to home
• Coordinate services provided within community

33
Long Term Follow-up

• Some symptoms are lifelong and require special
  expertise
• Emerging complications
• Changes in developmental stage
• Changes in social situation
• New treatments or technology
• Tune-ups
• Support and connectivity
• Aging with disability
• Scheduled and as needed (patients, families may
  not always be proactive)

34
A New Era of VA Care