RVOECRVOEC (Returning (Returning Veterans Outreach, Veterans Outreach,

Education and Care) Education and Care) ProgramProgram

Matt Camardese, MSWMatt Camardese, MSW

Baltimore VA Medical CenterBaltimore VA Medical Center

VA Maryland HealthcareVA Maryland Healthcare

Total OIF/OEF enrolled in MD/DC (VISN 5) VA Total OIF/OEF enrolled in MD/DC (VISN 5) VA system: system: 11,98411,984

Male: 75% (approx)Male: 75% (approx) Female: 25% (approx)Female: 25% (approx) 945,423 GWOT (Global War on Terror) veterans 945,423 GWOT (Global War on Terror) veterans

have left active duty and become eligible for VA have left active duty and become eligible for VA health care since fiscal year 2002 (as of Jan 09)health care since fiscal year 2002 (as of Jan 09)

• 51% former Active Duty Troops51% former Active Duty Troops• 49% Reserve and National Guard Troops49% Reserve and National Guard Troops

Demographic Characteristics of Demographic Characteristics of OEFOEF and and OIF OIF Veterans Utilizing VA Health CareVeterans Utilizing VA Health Care

% % OEF/OIFOEF/OIF Veterans Veterans (n = 299,585)(n = 299,585) SexSex Male 88 %Male 88 % FemaleFemale 12 12 Age GroupAge Group <20<20 6 6 20-2920-29 52 52 30-3930-39 23 23 ≥≥4040 19 19 BranchBranch Air ForceAir Force 12 12

ArmyArmy 65 65 MarineMarine 12 12 NavyNavy 11 11Unit TypeUnit Type ActiveActive 51 51 Reserve/Guard 49 Reserve/Guard 49 RankRank EnlistedEnlisted 92 92 OfficerOfficer 8 8

Common Issues Common Issues

3 most common issues reported by this 3 most common issues reported by this population (as cataloged by VA’s CPRS population (as cataloged by VA’s CPRS from encounter data from VA appts) from encounter data from VA appts)

----Diseases of Musculoskeletal Diseases of Musculoskeletal System/Connective System (710-739)System/Connective System (710-739)

--Mental Disorders (290-319)--Mental Disorders (290-319)

--Diseases of Nervous System/ Sense --Diseases of Nervous System/ Sense Organs (320-389) Organs (320-389)

Frequency of Possible Diagnoses Frequency of Possible Diagnoses of OEF/OIF Veteransof OEF/OIF Veterans

Diagnosis Diagnosis (n = 400,304)(n = 400,304) (Broad ICD-9 Categories)(Broad ICD-9 Categories) Frequency * % Frequency * %   Infectious and Parasitic Diseases (001-139)Infectious and Parasitic Diseases (001-139) 49,272 12.3 49,272 12.3Malignant Neoplasms (140-208)Malignant Neoplasms (140-208) 3,988 3,988 1.0 1.0Benign Neoplasms (210-239)Benign Neoplasms (210-239) 17,274 17,274 4.3 4.3Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 93,028Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 93,028 23.1 23.1Diseases of Blood and Blood Forming Organs (280-289) Diseases of Blood and Blood Forming Organs (280-289) 9,677 9,677 2.4 2.4Mental Disorders (290-319) Mental Disorders (290-319) 178,483 178,483 44.6 44.6Diseases of Nervous System/ Sense Organs (320-389) Diseases of Nervous System/ Sense Organs (320-389) 146,611 36.6 146,611 36.6Diseases of Circulatory System (390-459) 68,295 17.1Diseases of Circulatory System (390-459) 68,295 17.1Disease of Respiratory System (460-519) Disease of Respiratory System (460-519) 83,771 83,771 20.9 20.9Disease of Digestive System (520-579) Disease of Digestive System (520-579) 129,656 129,656 32.4 32.4Diseases of Genitourinary System (580-629) Diseases of Genitourinary System (580-629) 44,812 44,812 11.2 11.2Diseases of Skin (680-709) Diseases of Skin (680-709) 67,384 16.8 67,384 16.8Diseases of Musculoskeletal System/Connective System (710-739) Diseases of Musculoskeletal System/Connective System (710-739) 197,078 197,078 49.2 49.2Symptoms, Signs and Ill Defined Conditions (780-799)Symptoms, Signs and Ill Defined Conditions (780-799) 167,959 42.0 167,959 42.0

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

Disease Category (ICD 290-319 code) Disease Category (ICD 290-319 code) Total Number of Total Number of GWOT Veterans** GWOT Veterans**

PTSD (ICD-9CM 309.81)+ PTSD (ICD-9CM 309.81)+ 59,83859,838Nondependent Abuse of Drugs (ICD 305)++Nondependent Abuse of Drugs (ICD 305)++ 48,661 48,661 Depressive Disorders (311)Depressive Disorders (311) 39,940 39,940 Neurotic Disorders (300) Neurotic Disorders (300) 31,481 31,481 Affective Psychoses (296) Affective Psychoses (296) 22,216 22,216 Alcohol Dependence Syndrome (303) Alcohol Dependence Syndrome (303) 9,878 9,878 Special Symptoms, Not Elsewhere Classified (307)Special Symptoms, Not Elsewhere Classified (307) 5,802 5,802Sexual Deviations and Disorders (302)Sexual Deviations and Disorders (302) 5,577 5,577Drug Dependence (304)Drug Dependence (304) 4,447 4,447 Acute Reaction to Stress (308) Acute Reaction to Stress (308) 3,721 3,721

* * Note – These are cumulative data since FY 2002. ICD diagnoses used in these analyses are obtained from computerized administrative data. 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 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. the diagnosis is “rule-out” or provisional, pending further evaluation.

** ** A total of A total of 120,049120,049 unique patients received a diagnosis of a possible mental disorder. A veteran may have more than one mental disorder unique patients received a diagnosis of a possible mental disorder. A veteran may have more than one mental disorder diagnosis diagnosis and each diagnosis is entered separately in this table; therefore, the total number above will be higher than and each diagnosis is entered separately in this table; therefore, the total number above will be higher than 120,049120,049..

+ + This row of data does not include information on PTSD from VA’s Vet Centers and does not include veterans not enrolled for VHA health care. Also, This row of data does not include information on PTSD from VA’s Vet Centers and does not include veterans not enrolled for VHA health care. Also, this row of data does not include veterans who did not have a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment reaction this row of data does not include veterans who did not have a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment reaction (ICD-9 309).(ICD-9 309).

++++ 81% of these veterans (39,282) had a diagnosis of tobacco use disorder (ICD-9 305.1).81% of these veterans (39,282) had a diagnosis of tobacco use disorder (ICD-9 305.1).

Common Distress ResponsesCommon Distress Responses Sleep Problems—difficulty falling asleep; staying asleep or waking Sleep Problems—difficulty falling asleep; staying asleep or waking

early and difficulty getting back to sleepearly and difficulty getting back to sleep Restlessness---being jittery, fidgety or showing a high degree of Restlessness---being jittery, fidgety or showing a high degree of

nervous energynervous energy Hypervigilant—oversensitivity or anticipation about things in Hypervigilant—oversensitivity or anticipation about things in

environment that are viewed as a threat to self/other (e.g. loud and environment that are viewed as a threat to self/other (e.g. loud and sudden noises or movements)sudden noises or movements)

Social Withdrawal---Avoiding family/friends and social activities that Social Withdrawal---Avoiding family/friends and social activities that veteran had previously enjoyed. Wanting to be alone---e.g. veteran had previously enjoyed. Wanting to be alone---e.g. “Bunker” “Bunker”

Intrusive Thoughts—memories of deployment that could be Intrusive Thoughts—memories of deployment that could be triggered by environment or feeling as if they are back in war zone. triggered by environment or feeling as if they are back in war zone. Veterans are encouraged to share with others (censored for loved Veterans are encouraged to share with others (censored for loved ones) and seek help if sxs persist for more than 1 or 2 monthsones) and seek help if sxs persist for more than 1 or 2 months

More Serious ConcernsMore Serious Concerns Violence– Could be caused by Physical/Emotional problems and Violence– Could be caused by Physical/Emotional problems and

exacerbated by drugs/etoh. Violence towards self/other needs to be exacerbated by drugs/etoh. Violence towards self/other needs to be addressed immediately and safety plan for children/loved ones. Could be addressed immediately and safety plan for children/loved ones. Could be response to perceived threats, perceived betrayal, differences in response to perceived threats, perceived betrayal, differences in expectations, or, viewed as necessary to maintain sense of safety by the expectations, or, viewed as necessary to maintain sense of safety by the veteran. veteran.

Risk-Taking Behaviors—could be trying to get “rush” back, or, could be Risk-Taking Behaviors—could be trying to get “rush” back, or, could be viewed as necessary to maintain safety (e.g. driving fast/rapid lane viewed as necessary to maintain safety (e.g. driving fast/rapid lane changes, carrying loaded weapon on person), sexual promiscuity, looking changes, carrying loaded weapon on person), sexual promiscuity, looking for fights, or “policing” environmentfor fights, or “policing” environment

Substance Use—Increased use of alcohol and illicit drugs, even nicotine Substance Use—Increased use of alcohol and illicit drugs, even nicotine and caffeine (energy drinks like water) causing changes in overall health and caffeine (energy drinks like water) causing changes in overall health and well-being and mood. Medications (e.g. opiates, benzodiazepines) and well-being and mood. Medications (e.g. opiates, benzodiazepines) could have been prescribed for injury/mood/sleep in theater and may no could have been prescribed for injury/mood/sleep in theater and may no longer be needed.longer be needed.

Depressed mood—guilt, sadness, numbness, feeling aloneDepressed mood—guilt, sadness, numbness, feeling alone PTSDPTSD

PTSDPTSD A1—exposure to traumatic event (war, sexual trauma, car accident)A1—exposure to traumatic event (war, sexual trauma, car accident) A2a—event involved actual threat to well-being of self/otherA2a—event involved actual threat to well-being of self/other A2b—response involved fear, helplessness or horrorA2b—response involved fear, helplessness or horror B: B: Re-ExperiencingRe-Experiencing: Intrusive thoughts/memories, : Intrusive thoughts/memories,

dreams/nightmares, feeling as if you were back in situation dreams/nightmares, feeling as if you were back in situation (flashback—true dissociation), physical sxs: rapid heart beat and (flashback—true dissociation), physical sxs: rapid heart beat and sweating, getting upset when remided of traumasweating, getting upset when remided of trauma

C: C: AvoidanceAvoidance: efforts to avoid thoughts of trauma, staying away : efforts to avoid thoughts of trauma, staying away from people/places/things that remind Pt of trauma, trouble from people/places/things that remind Pt of trauma, trouble remembering events, loss of interests, numb/detached from others, remembering events, loss of interests, numb/detached from others, changes in future planschanges in future plans

D: D: ArousalArousal: trouble sleeping, irritability/anger, watchful/on guard, : trouble sleeping, irritability/anger, watchful/on guard, difficulty concentrating, easily startleddifficulty concentrating, easily startled

PTSD TreatmentsPTSD Treatments Individual InterventionsIndividual Interventions: CBT, CPT, Prolonged Exposure, Skill-Building, : CBT, CPT, Prolonged Exposure, Skill-Building,

Supportive Therapy, EducationSupportive Therapy, Education Group TherapyGroup Therapy: Specific groups (sleep hygiene, “HEAT,” anger mgmt) : Specific groups (sleep hygiene, “HEAT,” anger mgmt)

cohort groups, substance abuse & PTSD, family groupscohort groups, substance abuse & PTSD, family groups Support GroupsSupport Groups Family TherapyFamily Therapy: Baltimore VA partners with UMD’s Family Intervention : Baltimore VA partners with UMD’s Family Intervention

team, specific groups for family members with and without veteranteam, specific groups for family members with and without veteran Residential TreatmentResidential Treatment: intensive residential for PTSD and Dual Diagnosis : intensive residential for PTSD and Dual Diagnosis

(PTSD w/ Substance Abuse) at Baltimore, Perry Point, DC, Martinsburg and (PTSD w/ Substance Abuse) at Baltimore, Perry Point, DC, Martinsburg and Coatesville VAMC’s. Stabilization residential programs offered for aftercare, Coatesville VAMC’s. Stabilization residential programs offered for aftercare, step-down and return to care. step-down and return to care.

Group and Individual treatments also available for sub-threshold PTSD, or, Group and Individual treatments also available for sub-threshold PTSD, or, specific sxs of PTSDspecific sxs of PTSD

FamiliesFamilies Pay attention to behaviors and communication of veteran for any warning signs; Pay attention to behaviors and communication of veteran for any warning signs;

every veteran is unique and one size does not fit allevery veteran is unique and one size does not fit all Discuss expectations, new roles and go slowlyDiscuss expectations, new roles and go slowly Partnership: handle barriers together and share in successesPartnership: handle barriers together and share in successes Review available literature thru VA or on web (Battlemind.org, ncptsd.va.gov, Review available literature thru VA or on web (Battlemind.org, ncptsd.va.gov,

networkofcare.org, militaryonesource.com), book “Courage After Fire” available for networkofcare.org, militaryonesource.com), book “Courage After Fire” available for free at many VA’s.free at many VA’s.

Communicate with other families pre, during and post deployment for support and Communicate with other families pre, during and post deployment for support and help (especially important for National Guard and Reserve members)help (especially important for National Guard and Reserve members)

VA clinicians available to consult with as needed and as allowed by confidentiality. VA clinicians available to consult with as needed and as allowed by confidentiality. Family members can help with scheduling appts.Family members can help with scheduling appts.

Refrain from over-reacting/pathologizing, BUT, do communicate concern and offer to Refrain from over-reacting/pathologizing, BUT, do communicate concern and offer to help as neededhelp as needed

Do not accept violent/disrespectful/self-destructive behavior and could be a cry for Do not accept violent/disrespectful/self-destructive behavior and could be a cry for help. Use 911, ER’s and VA National Suicide Hotline: 800-273-TALKhelp. Use 911, ER’s and VA National Suicide Hotline: 800-273-TALK

Many service members re-adjust very well and over time sxs may resolve without Tx. Many service members re-adjust very well and over time sxs may resolve without Tx. Others may need professional help and family members can often serve as impetus.Others may need professional help and family members can often serve as impetus.

Addressing stigma: doesn’t mean veteran is “crazy”, re-adjustment counseling should Addressing stigma: doesn’t mean veteran is “crazy”, re-adjustment counseling should not affect security clearances as written into law (this is new; had served as barrier). not affect security clearances as written into law (this is new; had served as barrier). Common report from veterans accessing VA Care is sense of “aloneness”Common report from veterans accessing VA Care is sense of “aloneness”

OEF/OIF OutreachOEF/OIF Outreach

Clinical Reminders (Post-Deployment Screening)Clinical Reminders (Post-Deployment Screening)-Done on phone and during initial visits to identify -Done on phone and during initial visits to identify

MH concerns (PTSD, Substance Abuse and MH concerns (PTSD, Substance Abuse and Depression), GI complaints, skin concerns, TBI, Depression), GI complaints, skin concerns, TBI, MST, Suicide risk, and general medicalMST, Suicide risk, and general medical

-Why? To identify issues early and not limited to -Why? To identify issues early and not limited to those who come into the VA. All those enrolled those who come into the VA. All those enrolled in VA and identified as GWOT veteran need to in VA and identified as GWOT veteran need to be screened and VAMHCS requires above 90% be screened and VAMHCS requires above 90% completion rate at all times.completion rate at all times.

OEF/OIF OutreachOEF/OIF Outreach

Post-Deployment Health Re-Assessments: Done Post-Deployment Health Re-Assessments: Done 90 days after detachment from Active Duty.90 days after detachment from Active Duty. MD National Guard PDHRA’s are hosted by the MD National Guard PDHRA’s are hosted by the

Baltimore VA (1 of 3 VA Medical Centers in Nation to Baltimore VA (1 of 3 VA Medical Centers in Nation to Host these events)Host these events)

PDHRA Totals (as of Sept 2008):PDHRA Totals (as of Sept 2008):• Events: 18Events: 18• Veterans seen: 1,079Veterans seen: 1,079• Veterans Enrolled in VA: 550Veterans Enrolled in VA: 550• Primary Care Visits Scheduled: 339Primary Care Visits Scheduled: 339• Mental health visits Scheduled: 221Mental health visits Scheduled: 221

OEF/OIF OutreachOEF/OIF Outreach Other EffortsOther Efforts::

Annual Welcome Home Celebration (Navy Stadium 2008, Ripken Stadium 2007)Annual Welcome Home Celebration (Navy Stadium 2008, Ripken Stadium 2007) Visits to Reserve and Guard Centers and Active Duty BasesVisits to Reserve and Guard Centers and Active Duty Bases Job Fairs (Northrup Gruman, Bolling AFB, Camden Yards)Job Fairs (Northrup Gruman, Bolling AFB, Camden Yards) Visits to Demobilization Sites (Ft. Dix)Visits to Demobilization Sites (Ft. Dix) Outreach Phone CallsOutreach Phone Calls Reintegration events with MD Guard at 30 and 60 days post-deploymentReintegration events with MD Guard at 30 and 60 days post-deployment Combat Call Center: direct referrals to local VA POC’s in Primary Care, Enrollment, Combat Call Center: direct referrals to local VA POC’s in Primary Care, Enrollment,

Seamless Transition and Mental health from outreach workersSeamless Transition and Mental health from outreach workers Presentation at New Veteran OrientationPresentation at New Veteran Orientation VAMHCS Cable Show—Veterans’ Health WatchVAMHCS Cable Show—Veterans’ Health Watch Public Service Announcements and Appearances in Local Media Outlets (Baltimore Public Service Announcements and Appearances in Local Media Outlets (Baltimore

Examiner and Sun, NPR Radio, WJZ, WBFF, WBAL)Examiner and Sun, NPR Radio, WJZ, WBFF, WBAL) In-Service presentations and advertisements at VA/DoD sitesIn-Service presentations and advertisements at VA/DoD sites Membership in Community Veteran Committees—Balt Co, Dept of Labor, Yellow Ribbon Membership in Community Veteran Committees—Balt Co, Dept of Labor, Yellow Ribbon

CampaignCampaign Presentations about OIF/OEF Issues in Community: NAMI Annual Conference, AA Co Presentations about OIF/OEF Issues in Community: NAMI Annual Conference, AA Co

Police and County Police Negotiation Teams throughout MD, Wendy’s HR, CCBC, HoCo Police and County Police Negotiation Teams throughout MD, Wendy’s HR, CCBC, HoCo Comm College, PG Comm College, Northrup Gruman, Maryland Psychological Association, Comm College, PG Comm College, Northrup Gruman, Maryland Psychological Association, Towson, Univ of MD, McVets Annual Conference, VISN 5 Conference Towson, Univ of MD, McVets Annual Conference, VISN 5 Conference

Specific OEF/OIF ProgramsSpecific OEF/OIF Programs OEF/OIF Primary Care Clinic w/ behavioral health attachedOEF/OIF Primary Care Clinic w/ behavioral health attached Women’s HealthWomen’s Health AcupunctureAcupuncture TBI Triage and Treatment teamTBI Triage and Treatment team Seamless Transition OfficeSeamless Transition Office Wounded Warrior programWounded Warrior program Patient Transition AdvocatesPatient Transition Advocates HUD/VASH program through Section 8 (includes case mgmt)HUD/VASH program through Section 8 (includes case mgmt) Chronic Pain ClinicChronic Pain Clinic Polytrauma TeamPolytrauma Team*****Returning Veterans are eligible for 5 years of free VA care for all *****Returning Veterans are eligible for 5 years of free VA care for all

deployment-related injuries and 180 days of free dental care from deployment-related injuries and 180 days of free dental care from end of deployment/release from Active Duty (date from DD-214 end of deployment/release from Active Duty (date from DD-214 used).*******used).*******

VA Contact InformationVA Contact InformationMedical CentersMedical Centers::Baltimore: 410-605-7000 or (800) 463-6295 Baltimore: 410-605-7000 or (800) 463-6295 (Baltimore Seamless Transition Office—(410) 605-7259)(Baltimore Seamless Transition Office—(410) 605-7259)Perry Point: (410) 642-2411 or (800) 949-1003 Perry Point: (410) 642-2411 or (800) 949-1003 Martinsburg: (304) 263-0811 or (800) 817-3807Martinsburg: (304) 263-0811 or (800) 817-3807Washington, DC: (202) 745-8000 or (888) 553-0242 Washington, DC: (202) 745-8000 or (888) 553-0242

Regional Offices (Benefits and Claims Applications):Regional Offices (Benefits and Claims Applications):Baltimore: 31 Hopkins Plaza Baltimore: 31 Hopkins Plaza

Baltimore, MD 21201 Baltimore, MD 21201 Phone: 1-800-827-1000 Phone: 1-800-827-1000

Washington, DC: Washington, DC: 1722 I Street N.W.1722 I Street N.W. Washington D.C., DC 20421 Washington D.C., DC 20421 Phone: 1 800 827 1000 Phone: 1 800 827 1000

VA Contact InformationVA Contact Information

Vet CentersVet CentersBaltimore: (410)-764-9400Baltimore: (410)-764-9400Aberdeen: (410)-272-6771 Aberdeen: (410)-272-6771 Silver Spring: (301)-589-1073Silver Spring: (301)-589-1073Washington, DC: (202)-726-5212 Washington, DC: (202)-726-5212 Elkton: (410)-392-4485 Elkton: (410)-392-4485 Alexandria: (703)-360-8633Alexandria: (703)-360-8633Cambridge: (410)-228-6305 Cambridge: (410)-228-6305

Community-Based Outpatient Clinics (CBOC’s)Community-Based Outpatient Clinics (CBOC’s)Glen Burnie: 410-590-4140 Glen Burnie: 410-590-4140 Loch Raven: 410-605-7650 Loch Raven: 410-605-7650

VA Contact InformationVA Contact Information

CBOC’s, continuedCBOC’s, continuedFt. Howard: (410) 477-1800 or (800) 351-8387 Ft. Howard: (410) 477-1800 or (800) 351-8387 Greenbelt: 301-345-2463 Greenbelt: 301-345-2463 Washington, DC: 202-745-8685 Washington, DC: 202-745-8685 Alexandria: 703-313-0694 Alexandria: 703-313-0694 Cambridge: 410-228-6243 or (877) 864-9611 Cambridge: 410-228-6243 or (877) 864-9611 Pocomoke: 410-957-6718 Pocomoke: 410-957-6718 Charlotte Hall: 301-884-7102 Charlotte Hall: 301-884-7102 Hagerstown: 301-665-1462 Hagerstown: 301-665-1462

***OEF/OIF Veterans are eligible for 5 years of FREE VA Care for all ***OEF/OIF Veterans are eligible for 5 years of FREE VA Care for all deployment-related concerns, as well as 180 days of free Dental deployment-related concerns, as well as 180 days of free Dental care from the date indicated on their DD-214 (Discharge papers)care from the date indicated on their DD-214 (Discharge papers)

RVOEC teamRVOEC team

Baltimore DivisionBaltimore DivisionMatt Camardese, MSW 410-605-7000 ex 5732 (Loch Raven CBOC on Tuesdays)Matt Camardese, MSW 410-605-7000 ex 5732 (Loch Raven CBOC on Tuesdays)

Linda Zetter, CRNP 410-605-7000 ex 5659 (Glen Burnie CBOC on Fridays)Linda Zetter, CRNP 410-605-7000 ex 5659 (Glen Burnie CBOC on Fridays)

Sara Meyd, LCSW-C 410-605-7000 ex 5670Sara Meyd, LCSW-C 410-605-7000 ex 5670

Perry Point DivisionPerry Point DivisionPete Allman, LCSW-C 410-642-2411 ex 6167Pete Allman, LCSW-C 410-642-2411 ex 6167

Christina Watlington, PhD. 410-642-2411 ex 5427Christina Watlington, PhD. 410-642-2411 ex 5427

Washington, DC DivisionWashington, DC DivisionJennifer Cho, LCSW-C 202-745-8000 ex 5912Jennifer Cho, LCSW-C 202-745-8000 ex 5912

Questions?Questions?

Matt Camardese, MSWMatt Camardese, MSW 410-605-7000 ex. 5372 410-605-7000 ex. 5372

Matthew.Camardese@va.gov Matthew.Camardese@va.gov