Joint va dod task force recommendations adopt a public health approach
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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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Joint va dod task force recommendations adopt a public health approach

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

Joint va dod task force recommendations adopt a public health approach

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

Outreach inter agency collaboration

Outreach Inter-agency Collaboration

I northwest network deployment health summit regional conference nov 8 9 2004

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)

I northwest network deployment health summit participating stakeholders

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

I northwest network deployment health summit follow up monitoring of progress

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

Ii interagency memo of agreement purpose

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.

Ii memo of agreement cont d participating partners

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

Ii memo of agreement responsibilities

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

Ii memo of agreement service delivery outcomes from outreach

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%

Service delivery model

Service Delivery Model

Va pshcs mental health services for oif oef veterans organizational diagram

Vet Centers






Post-Deployment Clinic

Primary medical care

Mental health screening/triage

Poly-Trauma Clinic

TBI assessment &


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

Joint va dod task force recommendations adopt a public health approach

Collaborative and Coordinated Care





Deployment Health


PTSD Programs

Deployment health clinic integrated care for combat veterans

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

Deployment health clinic staffing seattle division

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

Improved access to care additional strategies

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

Patient preferences setting of care

Patient Preferences Setting of Care

Patient preferences types of service

Patient Preferences Types of Service

Treatment preferences modes of counseling delivery

Treatment PreferencesModes of Counseling Delivery

Patient preferences types of counseling

Patient Preferences Types of Counseling

Special clinical emphasis areas quality improvement needs assessment n 420

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

Special clinical emphasis areas quality improvement needs assessment n 4201

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

Special clinical emphasis areas quality improvement needs assessment n 4202

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

Special clinical emphasis areas quality improvement needs assessment n 4203

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



I prazosin for ptsd

I. Prazosin for PTSD

Prazosin for ptsd related nightmares

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.

First efficacy demonstration prazosin vs placebo crossover study

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

Results primary outcome measures

Results: Primary Outcome Measures

Raskind, MA et al., Am J Psychiatry 160:371-373, 2003.

Clinical global impression of change for overall ptsd symptoms

Clinical Global Impression of Change for Overall PTSD Symptoms


markedly improved

moderately improved

minimally improved

no change

minimally worse

moderately worse

markedly worse









Second efficacy demonstration prazosin vs placebo parallel group study

Second Efficacy Demonstration:Prazosin vs. Placebo Parallel Group Study

*p<0.01, **p<0.001

Raskind et al. Biol. Psychiatry 2007; 61: 928-934

Ii behavioral activation

II. Behavioral Activation

Alternative psychotherapies contraindications for evidence based ptsd approaches

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.

Behavioral activation

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.

Rates of response and remission bdi high severity subgroup

Rates of Response and Remission (BDI): High Severity Subgroup




Ba for treatment of ptsd

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.

Iii integrated care health promotion in ptsd

III. Integrated Care:Health Promotion in PTSD

Rationale for integrating health promotion into post deployment mental health care

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

Joint va dod task force recommendations adopt a public health approach

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



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.

Integrated care overview of clinical intervention

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.

Clinical outcomes 7 day point prevalence for non smoking status n 66

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

Joint va dod task force recommendations adopt a public health approach

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.

7 day point prevalence abstinence and percent reduction for continued smokers n 107

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


Assessment Period

Conclusions from preliminary work

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

Joint va dod task force recommendations adopt a public health approach





  • 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



Prevalence of ptsd stringently defined

Prevalence of PTSDStringently Defined

Distressing mental health symptoms liberal screening criteria iraq vets

Distressing Mental Health Symptoms Liberal Screening Criteria (Iraq Vets)

Barriers to mental health care vapshcs deployment clinic sample n 235

Barriers to Mental Health CareVAPSHCS Deployment Clinic Sample (N = 235)

Barriers to mental health care vapshcs deployment clinic sample n 2351

Barriers to Mental Health CareVAPSHCS Deployment Clinic Sample (N = 235)

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