1. Integrated Care/Integrative CareFor Returning Combat VeteransStephen C Hunt MD MPHNational Director, VA Post-Deployment Integrated Care Initiative 1

2. How can integrated/integrative care serve the needs of returning combat veterans? 3. What are the health concernsof newest veterans seen in the VA?1,285,631 of the 2.2 million who have deployed, are separated andeligible for VA50 % have been seen in VA between FY 2002 and April 2010 Musculoskeletal 54.7% Mental disorders50.7% Symptoms/signs49.2% Nervous system (hearing)42.5% GI (dental) 35.2% Endocrine/Nutrition 29.7% Injury/Poisoning27.5% Respiratory 24.9%VHA Office of Public Health and Environmental HazardsApril 20113 4. Since 2002, approximately 620,000 newest veterans have been seen in VA facilities. A total of 331,514 unique patients have received one or more psychological health diagnosesDisease Category (ICD 9: 290- 319)PercentagePTSD27.8%Depressive Disorders20.4%Neurotic Disorders17.2%Affective Psychosis 12.2%Alcohol Dependence5.7%Nondependent Abuse of Drugs 3.9%Specific Non-psychotic Psychological Disorder due to Organic Brain3.6%DamageSpecial Symptoms, not elsewhere classified3.4%Sexual Deviations and Disorders 2.9%Drug Dependence 2.8% This data excludes PTSD data from the VA Vet centers, the 90,303 with tobacco use disorder, the 22,156 with alcohol use disorder and the 17,188 with both TOB and ETOH but no other MH disorder. Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 20114 5. Comorbid Concerns in Combat Veterans Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009 JRR&D Sample = 340 OEF/OIF outpatients at Boston VATBI/Pain 12.6% 10.3% 5.3% P3 Multi-symptom Disorder 6.8%16.5%Overall prevalence:Pain 81.5% 42.1%TBI 68.2%PTSD 66.8%PTSDCLARK 2009 2. % 6. Rate the degree to which you believe Persian Gulf Illness is%Richardson RD, Engel CC, McFall, M, McKnightK, Hunt SC. Clinician Attributions forSymptoms and Treatment of Gulf War-RelatedHealth Concerns. Archives of Internal Medicine2001; 161: 1289-1294. 7. Rate the degree to which you believe Persian Gulf Illness, in general,is most effectively treated by%Richardson RD, Engel CC, McFall, M, McKnightK, Hunt SC. Clinician Attributions forSymptoms and Treatment of Gulf War-RelatedHealth Concerns. Archives of Internal Medicine2001; 161: 1289-1294. 8. Discover the potentials of integrated careCombat Non-injuryMarital/familycombat TBI financial injury difficultiesNon-combatillness Post-combatEnvironmental Spiritual / symptomsexposureexistential illnessstrugglesHearing lossC&Ptinnitus needs Mental health 9. With our returning combat veteransCombat Non-injuryMarital/familycombat TBI financial injury difficultiesNon-combatillness Post-combatEnvironmental Spiritual / symptomsexposureexistential illnessstrugglesHearing lossC&Ptinnitus needs Mental health 10. What are the stressors of war? PhysicalInjuryNoiseTemperature Sleep deprivationDietAustere conditionsToxic agentsInfectious agentsMultiple immunizationsBlast wave/head injury 11. What are the stressors of war?PsychologicalAnticipation of combatCombat traumaNon-combat traumaSeparation from family/homeDeprivation 12. What are the stressors of war? PsychosocialMarital/parenting issuesSocial functioningOccupational/financial concernsRisk of re-deploymentSpiritual/existential 13. Integrated Post-Combat CarePDICI (Post-Deployment Integrated Care Initiative 2008) Physical PsychologicalVeteran Psychosocial 14. Post-Deployment Integrated Care Facilities with Primary VAMCCBOC Psychological Health Integration(N=160/165) (N=34/49) Clinics Large CBOCs (>10,000 uniques in 2009) PDIC services in place79% 35% (clinic, cohort or consultative) PC-PHI staff in PDIC38% 12% Designated OEF/OIF Provider in52% 38% PC team PC-MHI Evaluation Survey 2010 McCarthy/ Brockmann14 15. Primary Care-Psychological Health Integration (Primary Care Mental Health Integration Initiative 2007) VeteranPH PCP Provider 16. VA Primary Care-Psychological Health Programs (N=157 VAMC sites) 2010 Survey 17. Post Deployment Care forRecent Combat Veterans: Connection and IntegrationESSENTIAL ELEMENTS: Comprehensive psychosocial and medical intake performed on allveterans: medical, psychological health and social worker all seeevery new patient during first visit. Primary care providers are trained and designated to function in thisrole. Close links to allied clinics, programs and modalities (CAM) Active participation by existing OEF/OIF program staff (OEF/OIFprogram manager and team, OEF/OIF Psychological Health teamsetc) featuring full integration of all post deployment services (includingCAM) Meetings (usually weekly-provider attendance essential) of the entireintegrated team to include CAM providers17 18. Post Deployment Care for Recent Combat Veterans:Connection and IntegrationRECOMMENDED ELEMENTS: Co-localization whenever possible for polytrauma,psychological health, pain, and physical therapy clinics.Same day access encouraged even when co-localization notpossible Extended hours availability Seamless telephone access; provisions for e-mail and textmessaging alternatives encouraged Integration of CAM modalities18 19. Post-Deployment Integrated Care Polytrauma Orthopedics Program PrimaryCareCAMDentalComp &Pension OEF/OIF WRIISCs OEF/OIF/ONDProgramVeteranPHManagerCAMTPA/SW-CMPainCAMWomensClinic Health Rehab Med/Suicide ProstheticsPreventionCoordinator 19 20. Team members Clinical pharmacy specialist: 3PACTpanels Clinical pharmacy Staffing Model anticoagulation: 5 panels Social work: 2 panelsThe Patients Nutrition: 5 panels Primary Care Case managers TraineesTeam Integrated behavioral health Psychologist 3 panels Social worker 5 panels Care manager 5 panels Psychiatrist 10 panelsTeamlet: assigned to1200 patients (1 panel) PCP RN care manager Clinical associate (LPN,medical assistant orhealth tech) ClerkPatient7/28/2011 20 21. Team membersClinical Pharmacy Specialist: 3 panelsClinical Pharmacy anticoagulation: 5 panelsSocial Work: 2 panels CAM in theNutrition: 5 panelsCase Manager OEF/OIF PACTIntegrated Behavioral Health Psychologist 3 panels Social Worker 5 panels Care Manager 5 panels Psychiatrist 10 panels OEF/OIF Program Manager Polytrauma/PainWRIISCsSUDCommunityResourcesPH Integration/CAMPCPClinical Associate (LPN,MA, or Health Tech)ClerkVeteranOEF/OIF CaseManager7/28/201121 22. Web Resources Public VA site with comprehensive information and links for returningservice members http://www.oefoif.va.gov/ VA Psychological Health services:http://www.mentalhealth.va.gov/ PTSD care with information for veterans and for providers:http://www.ptsd.va.gov Wellness resources for the military and veteran communities:http://www.afterdeployment.org VA/DoD Clinical Practice Guidelines : PTSD, TBI, MUS The National Resources Directory (NRD) provides access to servicesand resources at the national, state and local levels that supportrecovery, rehabilitation and reintegration:http://www.nationalresourcedirectory.gov/ VA has gone mobile to read and share VA information, news storiesfind facilities on the go: http://m.va.gov/ Information on environmental and occupational hazards duringmilitary: http://www.publichealth.va.gov/exposures/ 23. Integrative Health in the VA System of Care VA Office of Patient Centered Care and Cultural Transformation Patient Aligned Care Team Post-Deployment Integrated Care Initiative (PDICI) Planetree Polytrauma service, recreational therapy James A. Haley VA Chronic Pain Rehabilitation Program Salt Lake City VA VA Puget Sound War Related Illness and Injury Study Centerswww.warrelatedillness.va.gov/WARRELATEDILLNESS/education/conferences/2010-sept/slides/2010_09_15_SmeedingSJW_Developing-an-Integrative.ppt 24. Resources National Center for Complementary and Alternative Medicine at theNational Institutes of Health http://nccam.nih.gov/ White House Commission on Complementary and AlternativeMedicine Policy http://www.whccamp.hhs.gov/ Consortium of Academic Health Centers for Integrative Medicinehttp://www.imconsortium.org/ 25. March 2011Integrated/Integrative Approaches to Post-Deployment Care Its all about Connection Its all about IntegrationStephen C Hunt MD MPH National Director/Co-Director, Post-Deployment Integrated Care Initiative