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Joint VA/DoD Task Force Recommendations Adopt a Public Health Approach

VA Puget Sound Health Care System Innovations in Health Care of OIF/OEF Veterans Outreach Service Delivery Model Treatment Approaches Research. Joint VA/DoD Task Force Recommendations Adopt a Public Health Approach. Proactive case-finding through outreach

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Joint VA/DoD Task Force Recommendations Adopt a Public Health Approach

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  1. VA Puget Sound Health Care System Innovations in Health Care of OIF/OEF VeteransOutreachService Delivery ModelTreatment ApproachesResearch

  2. 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

  3. Outreach Inter-agency Collaboration

  4. 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)

  5. I. Northwest Network Deployment Health SummitParticipating 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

  6. 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

  7. 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.

  8. 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

  9. 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

  10. 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%

  11. Service Delivery Model

  12. Vet Centers Seattle Tacoma Bellingham Yakima Spokane Post-Deployment Clinic Primary medical care Mental health screening/triage Poly-Trauma Clinic TBI assessment & Rehabilitation VA PTSD Programs PTSD Clinical Teams women's' Trauma Team PTSD Inpatient Unit PTSD Domiciliary Affiliated Mental Health Programs Addictions Programs General Mental Health State Dept. Veterans Affairs 29 contract therapists VA PSHCS Mental Health Services for OIF/OEF Veterans Organizational Diagram

  13. Collaborative and Coordinated Care Center For Polytrauma Care Deployment Health Clinic PTSD Programs

  14. Deployment Health ClinicIntegrated Care for Combat Veterans 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

  15. Deployment Health ClinicStaffingSeattle 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

  16. 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

  17. Patient Preferences Setting of Care

  18. Patient Preferences Types of Service

  19. Treatment PreferencesModes of Counseling Delivery

  20. Patient Preferences Types of Counseling

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

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

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

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

  25. Research

  26. I. Prazosin for PTSD

  27. 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.

  28. 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

  29. Results: Primary Outcome Measures Raskind, MA et al., Am J Psychiatry 160:371-373, 2003.

  30. Clinical Global Impression of Change for Overall PTSD Symptoms Prazosin markedly improved moderately improved minimally improved no change minimally worse moderately worse markedly worse 1 2 3 4 5 6 7 Placebo

  31. Second Efficacy Demonstration:Prazosin vs. Placebo Parallel Group Study *p<0.01, **p<0.001 Raskind et al. Biol. Psychiatry 2007; 61: 928-934

  32. II. Behavioral Activation

  33. 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.

  34. 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.

  35. Rates of Response and Remission (BDI): High Severity Subgroup 76% 48% 49%

  36. 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.

  37. III. Integrated Care:Health Promotion in PTSD

  38. 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

  39. Integrated Care versus the Usual Standard of VA Care for Smoking Cessation in PTSD A Randomized Clinical TrialMcFall, M., et al. Improving Smoking Quit Rates for Patients with PTSD. Am J. Psychiatry 162:1311-1319

  40. 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.

  41. 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.

  42. Clinical Outcomes:7-Day Point Prevalence for Non-Smoking Status (n=66) % non-smoker Assessment Period GEE Analysis Results: Odds Ratio = 5.23, p < .0014

  43. Practice-Based IC for Smoking Cessation: An Open Clinical TrialMcFall, M. et al. Integrating Tobacco Cessation Treatment into Mental Health Carefor PTSD. American Journal of Addictions 2006; 15: 336-344.

  44. 7-Day Point Prevalence Abstinence and Percent Reduction for Continued Smokers (n = 107) Percent Assessment Period

  45. 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

  46. Partners Function Mental Health • Complicated/Severe cases • Patients who “accept” a PTSD Diagnosis • Specialized interventions • PTSD Inpatient and Outpatient programs • Addictions programs • Voc Rehab Services • Uncomplicated mental disorders • Screening, education, brief supportive Rx • Triage to Mental Health • Deployment Health Clinic • SCI and RMS • Poly Trauma Program Primary Care Specialty Medicine • Seamless Transition to MTF • Vet Center & VA Outreach • Drill Weekends Community Outreach Case Finding • Family Activity Day • PDHRA screening • Educational resources • VA & State DVA • Vet Centers • DoD (Military Director) • Dept. of Labor Interagency Collaboration • Sharing agreements • Cross referral • Educational meetings • Network Director • Facility Director • Service Lines • Resources • Organization • Mission priority Administrative Infrastructure

  47. Extras

  48. Prevalence of PTSDStringently Defined

  49. Distressing Mental Health Symptoms Liberal Screening Criteria (Iraq Vets)

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