e-Solutions January 2014
eSolutions: January 2014
Feature article: Our Opportunity to Serve Veterans
Grantee Feature: Centerstone: Connecting Vets to Care, Community
Quick Tips: 5 steps to serving vets in your area
Featured resource: Veterans Resource Guide
by A. Kathryn Power, M.Ed., Regional Administrator and Lead, Strategic Priority for Military Service Members, Veterans and their Families, SAMHSA
There is a misconception that veterans are only served through closed systems, and that the civilian community does not have the opportunity to interact with the veteran population.
From the standpoint of SAMHSA, only about 40% of people eligible for healthcare services are actually using Veterans Administration (VA) services, many of whom have behavioral health needs that have not been addressed.  In addition, there are a significant number of veterans who are ineligible for VA services, which includes those who were dishonorably discharged, perhaps due to undiagnosed behavioral health needs. This population and their families are showing up in community-based services. Some may be homeless.
We watched what happened when the Vietnam veterans came home, and no one wants to see that repeated. Even now, we are seeing high rates of suicide among Vietnam veterans. The trauma of war and the presence of being in a combat zone creates the potential for post-traumatic stress disorder (PTSD). Many of the people who have served in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) have served in multiple deployments. We’re seeing from the data that OEF/OIF veterans have high levels of trauma, such as PTSD.
We don’t know yet what is going to happen in the long-term, but we know we need to stay vigilant to ensure veterans have access. We have to be supportive and recovery oriented, and we want to be sure that these veterans and their families get the best and most relevant care. And that means integrated care.
We cannot continue with this notion of a separate mind and body. It is very important for people to understand that substance use, binge drinking, and other coping behaviors might signal a substance use disorder, and that all of this can be in combination with PTSD or other conditions common in veterans.
In 2006, SAMHSA started focusing on bridging the military-civilian divide. We worked with the VA to create the Veterans Crisis Line with the National Suicide Prevention Lifeline. In August 2012, the White House issued an executive order that challenged the Department of Defense (DoD), VA, and the Department of Health and Human Services (HHS) to collaborate to improve access to mental health services for veterans and their families. This includes hiring more people to work at the VA’s call center, a quality review of DoD’s healthcare programs, and having HHS partner more with the DoD and VA. We are doing a lot of work on the TRICARE benefit to ensure that it is consistent with the new mental health parity and addiction equity act, creating connectivity between the VA and community centers, and working across HHS agencies to get all kinds of healthcare providers to understand how to serve veterans and their families.
DoD, VA and HHS are also beginning to discuss how to collaboratively address needs of families of veterans. Families are incredibly important. During terms of service, families have gone through multiple deployments and years of isolation. If you are family of an active duty service member, the DoD has more than 100 programs to provide a variety of supports. However, once off active duty, a veteran’s family loses all access to these programs. Generally, the VA only treats veterans, not their families, and any families end up lost to the system. No one knows who they are, where they are, and there is no transition plan for their care.
Community providers need to be prepared to serve both veterans and their families. Community-based, integrated providers should continually educate themselves on helping veterans and should ensure that they understand the prevalence of certain conditions within this population. Providers should be knowledgeable about the experiences and demands of being in the military and shouldn’t be afraid to learn about the military system, language, and culture.
We need to be sure that people are asked if they have ever served in the military. We also need to make sure to ask clients if they are families of veterans or service members. If veterans or service members choose to go to a community based agency, we want them to get screened to identify all of their concerns. Healthcare professionals can provide SBIRT, give feedback about results of screening, describe risks, and advise ways for veterans and their families to address physical, mental and substance use concerns.
There is a wealth of sophisticated training and technical assistance for providers who want to engage more closely with this population. SAMHSA has materials about screening and evidence based practices that community providers can access, broken down for different levels of involvement.
The VA is continually looking at how to improve care, and it engages in research on the best ways to offer integrated services. Through their Center for Integrated Healthcare, providers can stay up to date on how the VA is approaching integrated care.
The future for serving our veterans and families needs to be integrated care. Let’s keep thinking and forming the ways we can offer this care to veterans and ensure that we do not deny veterans the opportunity to get care in local communities.
How are you addressing the needs of veterans, service members and their families in your community? Why is an integrated care approach helpful for your veteran clients? Share your experiences with us at firstname.lastname@example.org.
Several years ago, Jennifer Carr, program director at a veteran’s organization in the Nashville area, approached Centerstone with concerns about the lack of access to services for people returning from war. In particular, she was concerned about the suicide rate among service members and veterans.
One reason Carr approached Centerstone was because no other organization in the area was able to treat post-traumatic stress disorder (PTSD) directly. Other centers would refer out for these services, and she felt it was vital to have that capacity onsite.
Carr and Centerstone wanted to find a way to actively engage service members, veterans and their families. This initial conversation evolved into Centerstone Military Services, a nonprofit organization begun in 2010 that offers programs and services to ensure that all service members and their loved ones have the resources and support they need to lead healthy and fulfilling lives. One particularly innovative program is Courage Beyond, a nationwide program run by Centerstone offering confidential, free or low-cost programs and services to individuals and families through a supportive online community, retreats, and a 24-hour crisis line.
“Because of the prevalence of smartphones and digital technology, we can now present a low-cost, totally confidential service,” says Debbie Cagle, chief operating officer of Courage Beyond. In total, they host three online weekly groups through a webinar platform, and six forum-based groups, which involve at least ten people each day.
The biggest challenge in reaching this population is awareness, says Carr, now a program director at Courage Beyond. “The veterans are not coming to us not because they don’t feel like it. They don’t know we exist. When they do, they are telling their friends.”
“Once we engage them online, we can begin to let them know of the array of treatment options available” says Cagle. Currently, Centerstone Military Services provides about 400 counseling sessions each month. There are approximately 40-60 participants in each of their six online groups. While approximately 10% of Centerstone staff have been members of the military, all 15 peer mentors working with Courage Beyond, who facilitate the online groups and help transition people to the crisis line, are either veterans or family members. Even though they have a personal connection to the military, all peer mentors go through military cultural training to understand the different cultures across the different branches of the military. Staff also receive Applied Suicide Prevention Skills Training (ASIST) and communication training.
At Centerstone, they now have integrated primary care and behavioral health services co-located in many of their larger clinics. Throughout the company, if a veteran or family member walked in for services, and the staff recognize a crossover need, they can just walk them down the hall. And because they are set up for same-day access, the person wouldn’t have to make an appointment to be able to access the integrated services.
Carr and Cagle note that over the past 3 to 4 years, the Veterans Administration (VA) has become increasingly open to working with their center, although much of that has been informal. Carr notes that there are a “huge number of people who the VA cannot serve” because of their discharge status, including those who were dishonorably discharged.
Centerstone has two grants from the VA, one specifically for serving homeless veterans and another to provide telehealth services and improve access to services for members of the National Guard. Centerstone also operates an early connections grant program in the Clarksville, TN area to help infants and very young children, because of the need they see among military families surrounding Ft. Campbell. They work with nursery school workers, pediatricians on base, parents and both the primary care and mental health workforce to educate them on the impact of toxic stress to babies’ brains.
In addition to the services they provide in their centers in Indiana and Tennessee, since they engage with veterans and service members online, they contract with providers across the country to be able to refer individuals for services, as needed. Their priority is finding a professional who is licensed to help the specific and complex needs of veterans and service members.
Secondary to the importance of providing services and professional support to veterans and their families is ensuring that the veteran and family member is building connections and friendships. Conditions frequently seen in veterans and their loved ones, such as PTSD and secondary trauma, can be very isolating. “The more people we can get around those affected by PTSD or secondary trauma, showing they care, the more help we can provide,” adds Carr.
As providers aim to meet the needs of their communities, including veterans, there is an opportunity for integration of primary and behavioral healthcare to address the complex and whole health needs of service members, veterans and their families.
How can you be ready to engage veterans, service members and their families at your center? Here are five ways to start:
- Take a cultural competency course specific to the military: If you are serving this population, then you need to learn the nature and values of the military and some basics on how it is structured. For example, it is helpful if your clients don’t need to explain the difference between a navy and an army captain, what an MRE is, or what “extended deployment” means. The VA outlines a number of these learning opportunities on their website.
- Connect to the VA and other community veteran and service member groups: Learn if there are specific ways your center can complement the work of your area VA hospital, and create awareness among the local veteran community about the services you provide.
- Hire veterans: Members of the military want to interact with other members of the military, particularly when it comes to recovery and access to recovery services. Having the option for veterans-specific peer services helps create this bridge.
- Prepare staff to treat conditions frequently seen in members of the military: There are numerous centers dedicated to this training, including the Defense Centers of Excellence, the Center for Deployment Psychology, and SAMHSA’s Service Members, Veterans and Families TA Center.
- Know who else can help: Familiarize yourself with the veterans services available in your area, and nationwide. Check out the Veterans Resource Guide for more information.
CIHS compiled a Veterans resource guide to help you easily identify the array of educational services, trainings, and clinical tools that will help you provide the right assistance at the right time to the veterans and family members you serve. Keep this guide handy for quick reference when working with veterans and their families.
Learn about the distinctive needs and characteristics of rural service members, veterans, and their families; identify practical strategies for improving rural outreach, engagement, and access to services; and explore opportunities for partnerships with community-based organizations on a SAMHSA-hosted webinar, Strategies for Improving Rural Behavioral Health Services for Service Members, Veterans, and their Families, which was presented on January 30. The webinar also includes examples of new, integrated models of care and emerging technologies.
To mark the 50th anniversary of the first Surgeon General’s report on smoking and health, the Health Consequences of Smoking—50 Years of Progress reports on the changes over the past 50 years and the challenges which remain. Of note, some of the highest prevalence rates have been observed among those with complex comorbid medical illness, mental illness, alcohol and substance abuse disorders.
The Diabetes Education Toolkit, by the Center on Psychiatric Disability and Co-Occurring Medical Conditions, is a series of easy-to-understand patient education materials to help clients with mental illness better understand their diabetes or pre-diabetes. Care providers, family members, and other supporters may also find the information useful.
The latest issue of the Agency for Healthcare Research and Quality’s Health Care Innovations Exchange describes three different programs designed to promote employee health and wellness and reduce health care costs. Features include interactive tools and evidence-based strategies to design effective worksite obesity prevention and control programs; a scorecard to assess how evidence-based health promotion strategies are implemented at a worksite; and a toolkit for employers on how to implement a smoke-free workplace policy.
The National Institute on Minority Health and Health Disparities announced the release of The Health Disparities Pulse, a quarterly newsletter for the health disparities community that covers a wide array of topics, issues, and information pertaining to minority health and health disparities research and activities. To subscribe to the newsletter, or to share research updates, send an e-mail to NIMHDinfo@mail.nih.gov.
A strong integrated primary care and behavioral health workforce has clearly defined roles, core competencies, tailored staff development training, and strategies for recruiting and retaining employees focused on integrated care. Join CIHS to discuss the newly released set of core competencies for the integrated workforce, and to explore integrated care resources on job descriptions, workforce training, and recruitment and retention programs available. Date and time to be announced
Check out CIHS’ past webinars to see what you missed. Popular webinars in 2013 covered trauma-informed care, embedding behavioral health into primary care, and addictions treatment innovations.
 Co-Occurring Disorders and Military Justice. Substance Abuse and Mental Health Services Administration. www.samhsa.gov/co-occurring/topics/military-justice/index.aspx. Accessed January 31, 2014.
 Tanielian, Terri, Jaycox, Lisa H., et al. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation, 2008. http://www.rand.org/pubs/monographs/MG720.