The American Legion Presentation for the Institute of Medicine of The National Academies:

1. The American Legion Presentation for the Institute of Medicine of The National Academies: “Evaluation of the Department of Veterans Affairs Mental Health Services”

2. Health Care Policy Unit • Staff includes a Deputy Director, Assistant Director for Healthcare, Assistant Director for TBI and PTSD Programs, Senior Field Service Representative, Two Field Service Representatives and an Administrative Assistant • Primary responsibilities include the System Worth Saving Program, VHA issue analysis (Operations, Policy and Quality of Care) and New Initiatives, and researching TBI and PTSD programs • Performs veteran health care analysis, advocacy and training for American Legion at the national, state and local levels on VHA trends, programs and policies • Provides congressional testimony and communication on veterans health care for American Legion internal and external media (i.e. American Legion Magazine, Dispatch, Online Update, twitter, facebook, outside print, radio and TV interviews)

3. VETERANS HEALTH CENTER http://www.legion.org/veteranshealthcare

4. SYSTEM WORTH SAVING (SWS) PROGRAM • Founded in 2003 to assess the timeliness and quality of VA healthcare and provide feedback from veterans on their level of care • Three National Field Service Representatives and Task Force Members appointed by the National Commander conduct site visits at over 20 VA Medical Center Facilities annually • The site visit reports are compiled into a publication for the President, Congress and VA

5. SYSTEM WORTH SAVING (SWS) REPORT FOCUSES • Past reports have included leading veteran health care challenges such as: • Transition of Care from DoD to VA (2011) • Traumatic Brain Injury (2011) • Post Traumatic Stress Disorder (2011) • Rural Healthcare (2012) • Quality and Patient Satisfaction (2012) • Women Veterans Health Care (2013) • The current report for 2013-2014 is an overview of the10 year program past, present, and future of VA health care

6. SYSTEM WORTH SAVING CENTER http://www.legion.org/systemworthsaving

7. VETERAN MENTAL HEALTH STATISTICS • According to VA data, over 1.7 million veterans have separated from Iraq and Afghanistan but only approximately 60 percent of these veterans received health care in the VA • Since 2002, there has been 311,688 OEF/OIF/OND veterans that have been diagnosed with PTSD • Since 2002, there has been 572,569 (55.7%) OEF/OIF/OND veterans that have been diagnosed with a mental health disorder • According to January 2014 VA Suicide data 22 veterans commit suicide every day since 2010

8. CURRENT PRIORITIES • A TBI and PTSD Committee convened in 2010 to “investigate existing science, procedures as well as alternative methods for treating TBI and PTSD also known as the “signature wounds” that are not being employed by DoD or VA • Full-Time Assistant Director for TBI and PTSD Programs • Disseminated information on VA’s Crisis Line and worked closely with VA on the “Make the Connection” campaign to have veterans use their story to encourage other veterans to enroll • Stigma and Not Changing PTSD to PTS • Supported the establishment of the Veteran Treatment Courts

9. MENTAL HEALTH ACCESS CHALLENGES • Transition and Continuity of Care from DoD/VA • Joint DoD/VA Medical Record • VISTA Scheduling Package (i.e. telehealth, health care appointments to include mental health access) • Staffing/Vacancies (Continuity of Care) • Wait Times (Desired/Create date) • Extended Hours (VHA Directive 2013-001) 2- hours weekdays / 2 hours weekends • Improvements needed in performance metrics, MH staffing models, expansion of MH into PACT teams

10. MENTAL HEALTH QUALITY OF CARE CHALLENGES • Delay in research translating into clinical practice (average 15 years) • Over emphasis on medication management • Continued need for innovative treatments for PTSD such as CAM modalities • Continuity of care between VA and Non-VA providers (training, receipt of documentation, etc.) • Lack of outcome measurements/metrics on treatment success or drop out rates of treatment

11. TBI and PTSD Programs • Over the years, The American Legion has continued to be concerned with the unprecedented numbers of servicemembers and veterans returning from the Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) with Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD), which have been called the “signature wounds” of these conflicts. •  As a result, The American Legion convened a TBI and PTSD Committee in 2010 “to investigate existing science and procedures to include alternative methods for treating TBI and PTSD.” • The Legion conducted a three year independent study, in which the committee interviewed leading authorities and subject matter experts in the Departments of Defense (DoD) and Veterans Affairs (VA), mental health experts within the private sector, and caregivers of servicemembers and veterans about the treatments and therapies received or are currently receiving for their TBI and PTSD symptoms.

12. The War Within Report The committee released their findings and recommendations in a report called “The War Within.” This report specifically highlights treatments and therapies and identifies findings and recommendations to the DoD and VA.

13. Key Findings • Currently, there is no well defined approach to the treatment of TBI. Providers are merely treating the symptoms • The initial attempts to diagnose TBI is often complicated by the clinical overlap of symptoms of TBI, PTSD, and substance abuse disorder • The VA and DoD research studies are lacking for new innovative and non-pharmacological treatments such as virtual reality therapy, HBOT, and other CAM therapies. For the past several years most VA and DoD research has been conducted to only validate current evidence based therapies (CPT, PET, and antidepressants) • DoD and VA have no fast track mechanism in place to employ innovative or novel therapies in a standardized way

14. Recommendations • Congress provide oversight and funding to DoD/VA for innovative TBI and PTSD research currently being used in the private sector, such as hyperbaric oxygen therapy (HBOT), virtual reality exposure therapy (VRET), and other non-pharmacological treatments. • Congress needs to increase the budgets for DoD/VA to improve the research, screening, diagnosis and treatment, and direct DoD/VA to develop joint offices for collaboration between DoD/VA researchers. • DoD/VA needs to accelerate research efforts to properly diagnose and develop evidence-based treatments for TBI and PTSD.

15. Viewpoints The American Legion believes that all possibilities should be considered including alternative medicine and therapies in the attempt to find treatments and cures for these conditions that are affecting a significant numbers of servicemembers and veterans. If shown to be effective, these treatments, therapies, and cures should be made available to all who served their country and for those who continue to serve. The American Legion through the TBI and PTSD committee continues to build upon our knowledge and understanding of TBI and PTSD in order to provide Congress, DOD and VA with the data and recommendations they need to effectively treat servicemembers and veterans.

16. NEXT STEPS • TBI and PTSD Veterans Health Care Experiences Survey • Complementary and Alternative Medicine (CAM) Workgroup • Service member and Veteran Caregiver Workgroup

17. Warren J. Goldstein Assistant Director for TBI and PTSD Programs Veterans Affairs and Rehabilitation Commission The American Legion (202)263-5778 wgoldstein@legion.org QUESTIONS