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Northwest Network Post-Deployment Health Service Delivery Model

Northwest Network Post-Deployment Health Service Delivery Model. Components of An Effective System of Care. 1. Administrative Infrastructure 2. Interagency Collaboration and Sharing Agreements 3. Coordinated Outreach Activities 4. Integrated System of Care:

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Northwest Network Post-Deployment Health Service Delivery Model

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  1. Northwest Network Post-Deployment Health Service Delivery Model

  2. Components of An Effective System of Care 1. Administrative Infrastructure 2. Interagency Collaboration and Sharing Agreements 3. Coordinated Outreach Activities 4. Integrated System of Care: -Primary Care vs. Specialty Mental Health Care -VAMC-Based Care vs. Community Care

  3. Administrative Infrastructure

  4. Partners Function Mental Health • Complicated/Severe cases • Patients who “accept” a PTSD Diagnosis • Specialized interventions • PTSD Inpatient and Outpatient programs • Addictions programs • General Mental Health • Voc Rehab Services • Uncomplicated cases • Screening, education, brief supportive Rx • Triage to Mental Health • Deployment Health Clinic • Spinal Cord Injury and RMS Primary Care Specialty Medicine • Seamless Transition Program • Vet Center & VA Outreach • Drill Weekends for Reserve Units Community Outreach Case Finding • Primary Care Screen • Family Activity Day • DoD screening • Educational resources • VA & WA State DVA • Vet Centers • DoD • Dept. of Labor Interagency Collaboration • Sharing agreements • Cross referral • Educational meetings • Resources • Organization • Mission priority Administrative Infrastructure • Network • Facility • MH Service • Military Director • Federal & State

  5. 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

  6. Examples of System Building 1. Northwest Network Deployment Health Summit • 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)

  7. 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

  8. DOD and Washington National Guard Unit Locations Statewide BELLINGHAM C/898 EN ANACORTES C/898 EN OKANOGAN SPOKANE / FAIRCHILD AFB 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 EVERETT HHC 898 EN 215TH EIS SNOHOMISH A/898 EN McChord AFB 262nd IWAS 116TH WF POULSBO REDMOND 1-205th Reg (Ldr) SEATTLE 81 HQ HHC/A/C/181 BN 143RD CBCS BREMERTON B/303 AR KENT HHC 1-303 AR A/B/161 IN 281 MI WENATCHEE C/1-161 IN PORT ORCHARD B/303 AR 248 RAOC TACOMA Trp Cmd 341 MI EPHRATA 1161 TC Cheney 256th CBSC PUYALLUP E/303 CAV SHELTON MOSES LAKE C/1-161 IN BUCKLEY A/1-19 SF FORT LEWIS 81 REAR DET 66th Avn BDE E/168 AV B/14 EN OLYMPIA HHB 2-146 FA ELLENSBURG 116 RAOC MONTESANO A/2-146 FA YAKIMA B/181 BN 420 Chem BN 792 Chem Co 144th ARFOR 1-205th Reg (Ldr) PULLMAN B 2-146 FA CENTRALIA A/2-146 FA CAMP MURRAY – JFHQ 122 MPAD 111th ASOS’s SOD PAC 116th ASOC I/O GP 173rd MDF 1-205th Reg (Ldr) 252nd Group 254th Red Horse TOPPENISH HHC/1-161 IN CLARKSTON PASCO A/1-303 AR GRANDVIEW 791st Chem Co LONGVIEW C/2-146 FA WALLA WALLA A/1-303 AR VANCOUVER C/2-146 FA 792nd Chem A/1-19 SF CAMAS

  9. VAMC, Vet Centers, WDVA PTSD Program, WANG Family Support Sites Whatcom Pend Oreille San Juan Ferry Okanogan Skagit Stevens Island Clallam Snohomish Chelan Douglas Jefferson 9 King County PTSD Contractors Kitsap Spokane Lincoln Grays Harbor King Mason Kittitas Adams Grant Whitman Pierce Thurston Pacific Lewis Franklin Yakima Garfield Columbia Wahkiakum Asotin Benton Walla Walla Skamania Cowlitz VAMC Clark Klickitat RCSVet Center Joint WDVA and Vet Center Contractor WDVA PTSD Outpatient Contractor Site VA Community Based Clinic Site WDVA PTSD Program Outpatient Remote Site

  10. 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)

  11. 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

  12. 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 community-based PTSD contract providers

  13. Interagency Collaboration and Sharing Agreements

  14. 1. Interagency Memo of Agreement • 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.

  15. 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

  16. Washington State MOU

  17. Coordinated Outreach Activities

  18. MOU-Driven Outreach Plan and Responsibilities • 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 • 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

  19. Service Delivery Outcomes Family Activity Day Events • 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%)

  20. Health Screening and Triage at FAD • PDHRA Administration • Automated Scoring with Instant Feedback • On-Site “Second Tier” Screening and Triage

  21. 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%

  22. 2. Seamless Transition Program at MAMC (Total VA health care referrals = 3,156 [Sept-03 – 7-Apr-06]) Current Number and Percentage of Total Referrals to Date by Facility

  23. 3. Other Outreach Activities (Cont’d) • 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

  24. 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

  25. 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

  26. Integrated System of Care Reorganize Existing Programs Develop Innovative Programs

  27. Reorganize Existing Programs • 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)

  28. PTSD Specialty Services • PTSD Outpatient Clinic • PTSD Inpatient Evaluation and Brief Treatment Unit • PTSD Domiciliary

  29. PTSD Outpatient Clinic Seattle VA Medical Center Post-Deployment Readjustment Class

  30. 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

  31. Benefits and Challenges of Integrating OEF/OIF Veterans into Existing Mental Health Treatment Programs The PTSD Evaluation/Brief Treatment Unit Puget Sound Health Care System

  32. Operational Characteristics • 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)

  33. Commonalities • Nature of combat experiences • combatants not immediately identifiable • Guerilla tactics • Sociopolitical context of wars • Divisions in public attitudes toward war • Changing timelines and goals of military efforts • Marked Cultural/Ideological/Religious differences • Media coverage • Public access to images of war • Scandals involving war crimes

  34. Differences • Volunteer/Career Military • Broader range of ages, education, SES, previous training, gender • Media/Communications • Significantly less delay in reporting • Email, telecommunication options • Symptom profiles • Acute re-experiencing and hyperarousal symptoms, less entrenched avoidance behaviors • novelty of symptoms with recent recall of premorbid functioning

  35. Challenges to Integrated Treatment • Differences in experiences, life stage, and duration of symptoms • Can interfere with group cohesion • 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

  36. Benefits of Integrated Treatment • 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)

  37. Differences in Treatment Approaches for OIF/OEF Veterans Prioritizing most immediate/current issues • Stabilization of Acute Psychiatric Symptoms • Occupational and financial functioning • Relational functioning (divorce, infidelity, domestic violence) • Substance abuse issues; legal issues

  38. 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).

  39. Develop Innovative Clinical Programs 1. Deployment Health Clinic 2. Level II Polytrauma Center 3. Telephone-based tobacco cessation intervention

  40. 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 & medsmanagement Affiliated Mental Health Programs Addictions Programs General Mental Health State Dept. Veterans Affairs 29 contract therapists VA PSHCS Mental Health Services for OIF/OEF VeteransOrganizational Diagram

  41. 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

  42. Facility and Network OIF/OEF Workload DataFY02 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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