Mental Health Service System

Mental Health Service System By: Anthony Robinson, Bret Hirsch, Cleopatra Washington, Jennifer Schneider, Lindsay Johnson SW 622-53

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Post Traumatic Stress Disorder(Focus Area 1)

Lack of resources for adequate mental healthcare treatment PTSD is expressed differently, not every veteran will have the same symptomSymptoms include:Negative changes in beliefs & feelingsAnxietyFlashbacksDepressionNight terrorsSuicidal Ideation (picture from https://manyfacesofptsd.wordpress.com)

Population and Magnitude (Focus Area 1)Rates of PTSD among different era veterans (Administration, 2015):30% of Vietnam veterans12% Desert Storm veterans20% Operation Iraqi Freedom & Operation Enduring Freedom veteransOut of the 2.5 million OIF/OEF veteransEstimated 500,000 will return with PTSD (Research, 2014)331,000 veterans in Kentucky (Kentucky, 2016)Nearly 2 million veterans in California (Trounson, 2012)Injustice being created since there is minimal recording on a state level regarding PTSD

PTSD & Suicide(Focus Area 1)PTSD has devastating effects on veteransIncrease in depression and suicidal ideationDepression is a concurrent diagnosis with PTSD at a rate of 3 to 5 times higher than those without PTSD (Dept. VA, 2015)More likely to suffer from secondary or even tertiary psychiatric problems Since 2001, more U.S. military service members have died of suicide than killed in actionBetween 2001-2007 Deployed veterans had a 41% higher suicide rate than civiliansNon-deployed veterans had a 61% higher rate During this study there were 317,581 troops deployed and 1,650 committed suicide Out of the 964,493 troops that were not currently deployed, 7,703 committed suicide (Kang, 2015)

Scope(Focus Area 1)The scope of this social problem is wideVeterans suffer along with their families, friends and communities Financial strain created by treating PTSD outside of the VACan range from $1,100 - $4,700 per veteran a year (Hill, 2014)Economic cost of PTSD, due to depressionEstimated between $4-$6 billion over two years (Tyson, 2008)

(Picture from Veteransvisionproject.com)

Treatment(Focus Area 1)Treatment for PTSD in veterans is often the same as treating psychiatric disorders in other populations Group/individual therapy and medicationProlonged exposure therapy Utilized to desensitize veterans from sounds, smells or situations that may trigger a PTSD episode (Bergland, 2013)Magnetic Resonance Therapy (MRT)Alleviate symptoms of PTSD(Leiby, 2015)Esoteric treatment avenues are being investigatedPsilocybin (magic mushrooms), MDMAHelp veterans make peace with the traumas they experienced (Vastag, 2010)

Benefits and Services for Veterans(Focus Area 2)Eligible combat veterans receive free care and medications for conditions related to their service in theaterImmediate health care coverage after serviceNo enrollment fee, monthly premiums or deductiblesLow or no out-of-pocket costs- May have to pay for some care not related to combat injuries. More than 1,700 places available to receive health care. VA health care can be used along with Medicare and other insurance coverage (Department of Veterans Affairs, n.d.)

Urgent Need for New Policies(Focus Area 2)Clinical and Research Perspectives PanelFocus on current mental health needs of OIF/OEF veteransEnsure clinical practitioners have access to effective treatments and screening proceduresCurrent research shows nearly 60% of OIF/OEF veterans are no longer affiliated with active military serviceNearly 20% of these veterans returned from combat with PTSD or TBI Estimated that only half of these veterans seek treatment High prevalence of mental health disorders contributes to suicide

(Reserve Officers Association, n.d.)(Mental Health Association in PA, 2013)

Addressing Inadequate Services(Focus Area 2)2014- Veterans Access, Choice and Accountability Act: Expand access to care by allowing usage of non-VA facilities if they live 40+ miles away from a facility or have to wait 30+ days for an appointment2014- Jacob Sexton Military Suicide Prevention Act: Enacted as part of the national defense bill, requires annual mental health assessment for service members. Also requires the Pentagon to evaluate existing military mental health practices and make improvements2015- Clay Hunt Act: See slide 11 & 122016- Female Veteran Suicide Prevention Act:VA must identify mental health care and suicide prevention programs most effective for female veterans, also identify the programs with the highest satisfaction rates among women veterans

Proposed Legislation(Focus Area 2)2013 (reintroduced 2015)- Veterans Mental Health Accessibility Act:Combat veterans from all eras eligible for hospital care, medical services and nursing home care for any mental illness through VA, notwithstanding insufficient medical evidence 2015- Prioritizing Veterans Access to Mental Health Care Act:Amend the Veterans Access, Choice and Accountability Act, allow veterans non-VA care if they can show the agency is not giving them adequate or timely care2015- Veterans Mental Health Accessibility Act:Amend title 38, United States Code, to provide for unlimited eligibility for health care for mental illnesses for veterans of combat service during certain periods of hostilities and war

Clay Hunt Act(Focus Area 2)2015 Clay Hunt Act: requires annual third-party evaluations of VAs mental health care and suicide prevention programs, creates a centralized website with resources and information for veterans about the range of mental health services available from the VA, and requires collaboration on suicide prevention efforts between VA and non-profit mental health organizations.

(Picture: http://iava.org/savact/)

Clay Hunt Act: Changing Social Work(Focus Area 2)Suicide prevention hotline send information daily to VAList of callers and their needs24 hours to call veteran and conduct phone consultation for servicesSee patient within 48 hours if presenting suicidal ideationSpecific to Louisville social workPsychiatric staff in ER to assess patientsSuicide prevention coordinators/case managers: 48 hours to see clientServices for patient must be organized within that time frame New policies help social workers reach more veterans in need

(Personal, Stacy Hagman, 2015)

Clay Hunt (Focus Area 2)double click the screen if the video does not automatically start

Is Mental Health Care Funding Adequate?(Focus Area 3)Mental healthcare has available funding at state and federal levelsFunding for veterans healthcare is availableDifficulty obtaining an ample amount of funding to cover those in needCalifornia-Received $101,061,596 in grants for treatment in 2015 according to SAMHSAFunding in form of grants and discretionary fundingDiscretionary funding not targeted towards veteransKentucky:Received $13,702,060 in grants for treatment in 2015 according to SAMHSAFunding not directed towards veterans

Funding is Not Adequate(Focus Area 3)Without amble funding, veterans do not receive proper treatmentIn 2014, VA was allocated $54.6 billion for healthcareOnly $6.9 billion targeted for mental healthcare in the VAIn 2015 the budget was decreased to $50.49 millionNo report on total funds allocated to mental healthcare Need for transparent funding, budgets and reporting regarding mental healthcare to determine adequate funding response

(picture from https://blogs.extension.org/militaryfamilies/tag/ptsd-and-military)

California(Focus Area 4)The VA Greater Los Angeles Healthcare System (VAGLAHS) is the largest healthcare system within the Department of Veterans Affairs. It is one component of theVA Desert Pacific Healthcare Network (VISN22)offering services to Veterans residing in Southern California and Southern Nevada. VAGLAHS consists of three ambulatory care centers, a tertiary care facility and 10 community based outpatient clinics. There are 1.4 million Veterans in the VAGLAHS service area. VAGLAHS is affiliated with both UCLA School of Medicine and USC School of Medicine, as well as more than 45 colleges, universities and vocational schools in 17 different medical, nursing, paramedical and administrative programs.

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California(Focus Area 4)Southern California has one of the largest concentrations of veterans of any region in the U.S. Greater Los Angeles VA system in 2013Handled more than 1.2 million outpatient visits Treated 90,000 new patients Issues the CA service system is facingProviding access to careContinuity of careMismanagement of care

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Fragmentation and Critical Gaps

Long Wait Times for Appointments (60 90 days).

Long Waits for Specialty Appointments (up to 8 months or longer)

Heavy Appointment Loads

Inconsistent Patient Care (Revolving Door for Physician and Providers)

Limited Access to Care (Veterans Fall Through the Cracks)

Over Medication of Anti-Depressants without Proper Follow-Up Care

California: Fragmentation & Gaps(Focus Area 4)

Long wait times: 60-90 daysLong wait times for specialty appointments: 8+ monthsHeavy appointment loadsInconsistent patient careRevolving door for physician and providersLimited access to careVeterans falling through the cracksOver medication of anti-depressantsLack of proper follow-up care

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California: Problems in System(Focus Area 4) Problems within the whole system areBudgeting concerns, bureaucracy issues, Leadership problems, mismanagement, And a lack of proper leadership

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California(Focus Area 4)

According to the San Diego Tribune, at least 27 veterans under age 45 died by suicide in San Diego County between 2014 and the first half of 2015.The majority suffered from depression or post-traumatic stress disorder after serving in a combat zone since the Sept. 11, 2001, attacks. families of some of these veterans witnessed a revolving door of health care providers, in part because VA medical centers are teaching hospitals. Some question the amount of medication prescribed in these cases. Nearly all commonly used antidepressants list suicidal thoughts as a possible though rare side effect, particularly for people under 25.

(picture:heartfeltleadership.com)

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An internal investigation by the U.S. Veterans Affairs department has found that the San Diego VA system botched its care of former Camp Pendleton Marine Jeremy Sears, who killed himself at an Oceanside gun range in October 2014 (San Diego Union Tribune, 2016). The combat veteran waited 16 months to hear that he would receive no disability pay after serving multiple tours in Iraq and Afghanistan and being diagnosed with a brain injury. Critics said the VA's medical and benefits divisions let Sears fall through the cracks and more could have been done to save his life.

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California(Focus Area 4)

Wendy Clouser of Big Bear Lake has been taking post-traumatic stress disorder medications one of them experimental for two years. She hasnt seen a psychiatrist at the Jerry L. Pettis Memorial VA Medical Center in Loma Linda to evaluate the medications since the day she picked up the prescriptions. But not for lack of trying, she said. I make an appointment and it gets cancelled. Then I call back to make another appointment and they call and cancel again, said Clouser, a wheelchair-bound Army veteran (Press Telegram Veterans Affairs).

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Kentucky: Mental Health Service System (Focus Area 4)

Kentucky: Lack of Collaboration Creates Consequences (Focus Area 4)2005-2011 study - 26.57% increase of veteran suicides Largest increase in country compared to overall veteran populationStory of Marine veteran Cameron AnestisWent to VA in Lexington to seek helpTold he needed to go to another centerDenied service at second center due to form issueCommitted suicide after leaving facility U.S. Marine Cameron Anestis (Hewlett, 2011)(Hargarten, Burnson, Campo & Cook, 2014)(picture from combatptsdwoundedtime.org)

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Kentucky: Collaboration to Eliminate the Gap (Focus Area 4)Lack of accessibility to service causing rural veterans to sufferLack of services Minimal competition within entire systemMaking strides towards collaborating to provide servicesEnactment of VA Choice programJoining Community Force Initiative New programs Directed towards providing more options for local and adequate servicesAssisting veterans with understanding the options available for care

(U.S. Dept of Veterans Affairs, n.d.)(Joint Services Support, n.d.)

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Group NetworkingAnthony RobinsonOrganization: Active Heroes - Military Family Community Center (MFCC)Met with: Adriane Howard-South, CoordinatorI had a phone interview with Adriane Howard-South on March 17, 2016. Due to post-surgical mobility issues and driving restrictions I was given dispensation to conduct this via phone rather than in person. During this conversation Ms. Howard-South was very open and willing to answer the questions that I put forward to her.Active Heroes is a 503c3 non-profit organization dedicated to providing veteran and active duty military, as well as their families, support through physical, educational, and coping skills programming in an effort to reduce and, ultimately, eliminate veteran suicide. The organization was created out of the efforts of Troy Yocum who raised awareness around veteran suicide when, between 2010-11, he hiked across 37 states over 17 months, covering 7,800 miles, and raising over 1.3 million dollars. Mr. Yocum was motivated by his grandfather, who served during World War II in the Pacific theatre. After his service, Mr. Yocums grandfather suffered from PTSD until he committed suicide in 1980.Ms. Howard-South discussed the MFCC which provides a host of services for veterans and their families. The MFCC offers their clientele a safe space to get away from the day to day pressures of the military, both those placed on the veteran and those on the family. They offer a wide variety of engagement opportunities including; acupuncture, crossfit, yoga, meditation, as well as financial and career seminars, and family nights. These are open to all military personnel and their families. The center also hosts Sounds of Acoustic Recovery (S.O.A.R.), which provides guitar lessons for veterans by veterans. This group is only open to current or past service members with the goal of using music as a therapy and building camaraderie between the members.The MFCC and the programming offered are a holistic and proactive approach to helping prevent veteran suicide. To quote Ms. Howard-South, the whole point of this is prevent the crisis that can lead to suicide. It is hoped that creating an atmosphere where families can bond, veterans can find camaraderie, and a community of people can support each other will help mitigate the isolation that can lead to depression and suicide.

Group NetworkingBret HirschI talked with Ms. Jennifer Skaggs, the Outpatient Coordinator for the PTSD Clinical Team at the Louisville VA. We discussed how the number of veterans returning with PTSD are at an all time high and the resources are still inadequate to fully work with everyone who needs assistance. We talked about how veterans are hesitant to seek assistance since they have been ingrained to be strong and not show any weakness, even to mental illness. We discussed how people need to know how to recognize the signs of PTSD and be aware of the resources available should they need to utilize or make referrals. She talked about the need for more staffing and funding to meet the demands of the outreach and support needing to be provided.

Group NetworkingLindsay JohnsonI met with Stacy Hagman, Suicide Prevention Coordinator at the VA in Louisville, on 3/24/2016. We met in her office and I conducted a brief interview with her about her thoughts on the suicide prevention tools, barriers to mental health, and her role as a social worker. Stacy is new to the position as of a year ago, so she's very much still learning the world of the VA. She reported that in 2007 every VA was required to have a suicide prevention program that was offered, which created the role for suicide prevention coordinator. Now, they have expanded and have included one more coordinator and a case manager to the program. Stacy, and other coordinators, are responsible for community outreach, organization of services with veterans, conducting clinical groups, and education/training to ALL staff at the VA. Regardless of position, every staff member must be trained in suicide prevention, either as a gatekeeper or at a clinical level, depending on job duties. Also, they have adopted a "flag system" within the VA that flags a medical record (they are all digital) if a client is experiencing suicidal thoughts so that all practitioners involved in a veteran's care are aware to continue to assess for suicidal behavior. Stacy also talked about their inclusion of evidence based practices in their pursuit of suicide prevention. She stated that a barrier to care is that more rural areas don't have the connection or training on EBP's like the more urban VA centers have. She would have more time in a perfect world to train these staff so that there is no disconnect between services depending on location. Another barrier she mentioned was the disconnect between the DOD and the VA. For example, active duty members shy away from reporting mental health issues because they are then evaluated by a professional (who is also an officer in the military) and they lose the autonomy over their care. This officer can also make recommendations on their jobs or extend the time to being discharged, so that they can avoid outsourcing for treatment. This creates a stigma among military service members and they will often lie about their issues out of fear. This affects the VA because that same mentality transfers over and they are in fear of recovering from their issues because they might lose their service connection (benefits). So, her last barrier was really about the disconnect between offering services but not being recovery oriented as far as administrative pieces are concerned.

Group NetworkingCleopatra Washington

I had the privilege of networking with an amazing Social Worker and advocate for the Armys AW2 program. Vicky Hamilton is a U of L Kent School of Social Work Masters program graduate and a proud US Army Retiree. She is also the founder of Radcliffs Soup Kitchen and is extremely passionate about helping soldiers and their families. Her passion is infectious and I was truly inspired by her compassion and concern for helping others. Ms. Hamilton has been an advocate for 12 years and expresses how thankful and blessed she feels to have such an amazing position working as a civilian for the U.S. Army. She also expressed how the program has grown over the past 12 years and how that has had a major impact on her ability to help soldiers and their families.The AW2 program I visited was located in the Ireland Army Community Hospital, Fort Knox, Kentucky. This program provides transition support services to severely wounded, ill and injured soldiers within the Fort Knox community and surrounding areas. The program directly impacts the overall success of the soldier as they maneuver through a very complex system ensuring that the soldier and their family receive all the benefits they are entitled to having. The AW2 advocate ensures that all aspects of a soldiers transition from military life to civilian life are seamless and uneventful in order to decrease unnecessary stressors. The AW2 program counselor collaborates with military and civilian organizations to advocate for the soldiers benefits and ensures a soft handoff to the Department of Veterans Affairs.What I found to be unique about this program is the fact that the advocate continues to follow the soldier after they transition out of the military. The advocate calls the soldiers as often as necessary, sometimes daily, weekly and monthly to ensure they are okay. Ms. Hamilton stated, I will do anything to make sure every one of my soldiers are okay. She also stated, I will speak to anyone and go anywhere necessary to ensure my soldiers have all their benefits and are being treated with respect and dignity. No other military program provides this type of outreach service and the need is extremely necessary with the high numbers of veteran suicides.

Group NetworkingJennifer Schneider On March 22nd, 2016 I met with SSgt. Robinson of the Kentucky National Guard. SSgt Robinson holds a contract position with the KY National Guard and plays a major role within the Joining Community Forces Initiative. His duty is to travel across Kentucky and make connections with for-profit, non-profit and government services which will benefit veterans. Kentucky has a disconnection with rural veterans and these veterans often do not know the services that are available for them. SSgt Robinson is helping to create a state wide resource map which will allow a veteran to type in their location and type of service needed to see a list of services within their requested radius. Partnerships SSgt Robinson is creating covers many different areas of need from mental help to financial assistance. This initiative will also be beneficial to social workers within the 15 VA satellite health care facilities across the state. A case worker will be able to utilize the tool to help find services closer to the home of the veteran they are serving. Once the tool is completed, SSgt Robinson and his team will be in charge of conducting reviews of the partnership services. These reviews will ensure the businesses and agencies within the Joining Community Forces Initiative are providing proper care for veterans. SSgt Robinson understands the critical need for this tool within the state of Kentucky since he also lives in a rural area. He stated numerous times that rural veterans do not understand how to find the services available for them, if they make 1-2 calls and agencies cannot help them, they simply give up on finding help. SSgt Robinson has come into contact with many rural veterans who have been in dire need of assistance. Many of the veterans told him similar stories of not being able to find assistance without driving 2-4 hours away from home. His goal is to break down the image of Louisville and Lexington being the only areas for veterans to receive help. Many assume that they can only receive help in the two cities because that is where the two VA hospitals are located. SSgt Robinson hopes the Joining Community Forces Initiative will begin to create a sense of collaboration within the service system. While he understands this is not a tool to fix the entire system, he hopes it will begin to pave the way for a stronger service system for veterans in Kentucky.

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ReferencesMental Health Association in Pennsylvania. (2013). Veterans Mental Health Accessibility Act. http://www.mhapa.org/wp-content/uploads/2013/04/Vets-Mental-Health-one-pager.pdfReserve Officers Association. (n.d). Meeting the Mental Health Needs of Military and Veterans: Challenges & Solutions. Retrieved from https://www.roa.org/ROA-blog/meeting-mental-health-needs-military-and-veterans-challenges-solutionsU.S. Department of Veteran Affairs. (2013). Office of Public and Intergovernmental Affairs. Retrieved March 04, 2016, from http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2427Department of Veteran Affairs. (n.d). VA History in Brief. http://www.va.gov/opa/publications/archives/docs/history_in_brief.pdfLincoln Trail Behavioral Health (n.d.). Mission Wellness Military/Veteran Program. Retrieved from http://www.lincolnbehavioral.com/phy-military.aspU.S. Census Bureau. (2012). Kentucky State & County Data. Retrieved from http://quickfacts.census.gov/qfd/states/21000lk.htmlJoint Services Support (n.d.). Supporting Our Nation One Community at a Time. Retrieved from https://www.jointservicessupport.org/communityforces/About.aspxHargarten, J., Burnson, F., Campo, B., & Cook, C. (2014) Suicide rate for veterans far exceeds that of civilian population. The Center for Public Integrity. Retrieved from http://www.publicintegrity.org/2013/08/30/13292/suicide-rate-veterans-far-exceeds-civilian-populationHewlett, J. (2011) Lexington VA facilities denied veteran help before suicide. Lexington HeraldLeader. Retrieved from http://www.kentucky.com/news/local/crime/article44075940.htmlU.S. Department of Veterans Affairs (n.d.) Veterans Choice Program. Retrieved from http://www.va.gov/opa/choiceact/#Lincoln Trail Behavioral Health (n.d.). Mission Wellness Military/Veteran Program. Retrieved from http://www.lincolnbehavioral.com/phy-military.aspU.S. Census Bureau. (2012). Kentucky State & County Data. Retrieved from http://quickfacts.census.gov/qfd/states/21000lk.htmlJoint Services Support (n.d.). Supporting Our Nation One Community at a Time. Retrieved from https://www.jointservicessupport.org/communityforces/About.aspxHargarten, J., Burnson, F., Campo, B., & Cook, C. (2014) Suicide rate for veterans far exceeds that of civilian population. The Center for Public Integrity. Retrieved from http://www.publicintegrity.org/2013/08/30/13292/suicide-rate-veterans-far-exceeds-civilian-populationHewlett, J. (2011) Lexington VA facilities denied veteran help before suicide. Lexington Herald Leader. Retrieved from http://www.kentucky.com/news/local/crime/article44075940.htmlU.S. Department of Veterans Affairs (n.d.) Veterans Choice Program. Retrieved fromhttp://www.va.gov/opa/choiceact/#