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					 Statewide TBI Webinar Series


Veteran Culture & VA Service Coordination
  Northern California
    April 25, 2011
    Teleconference:
      1-888-450-5996
      PASSCODE: 326087#         ^ CATBI.org Logo
            ARRA Grant Funded (11/2009-9/2011)
Webinar Features

        Chat

        Step    Out
        Closed-Captioning

        Change    Layout
        Polls

        Audio
Agenda and Presenters
Northern California
    Welcome                                   Doug Chandler
    Veteran and Military Culture              Jeremiah Ridgeway
    What’s Unique about Vets w/ TBI           Dr. Cynthia Boyd
    Service Coordination                      Laura Gomez
    Veteran Outreach & Perspective            Chris Lopez
    Questions and Answers
    Wrap-up Discussion

    Technical Support
      Neal Albritton – IT Consultant
      Crystal Loutzenhiser – TBI Project Assistant
WELCOME

   Purpose of webinar
      Fostering collaboration and cross referral

       between VA and community organizations to
       better serve the unique needs of veterans,
       veterans with TBI and multiple disabilities.
      Connecting Independent Living culture with

       veteran culture
   Webinar Participants
VETERAN AND MILITARY CULTURE S.C

    Jeremiah Ridgeway
        Served in the Army in
         Afghanistan during Operation
         Enduring Freedom.
        Photo essays published in BBC
         and his National Geographic
         combat photography and
         personal stories earned an
         Emmy nomination.
        Jeremiah is a Readjustment
         Counseling Technician at Santa
         Cruz County Vet Center.
                                          ^ Vet Center Logo



                  U.S. Dept. of Veterans Affairs.
COMBAT CULTURE




Photo of
Three
Soldiers
>>
Understanding the language
   GWOT – Global War on                RPG – Rocket Propelled
    Terror                               Grenade
   OEF - Operation Enduring            IED – Improvised Explosive
    Freedom                              Device
   OIF - Operation Iraqi Freedom       TBI – Traumatic Brain Injury
   OND – Operation New Dawn            PTSD – Post Traumatic
   Post 9/11 Veterans                   Stress Disorder
   In Theatre / Down Range             Poly Trauma – Multiple
                                         Injuries
   MOS – Military Occupational         COS - Combat Operational
    Specialty                            Stress
   DD214 - Discharge from Active       MST – Military Sexual
    Duty Form 214                        Trauma
   www.rivervet.com/oif_glossary.      BATTLE MIND
    htm
 Post War Readjustment




Army Pfc.
Joseph
Dwyer
carrying
injured
Iraqi
child
2003 >>
  Comrades in Arms




Army
 Specialist
Zachary
 Boyd
in I love NY
pink boxers
in fire fight in
Afghanistan
2009
BATTLE MIND

Combat skills and battle mindset that
 sustained survival in the combat-zone
 Buddies (cohesion) vs Withdrawal at home
 Accountability vs Control

 Targeted Aggression vs Inappropriate Aggression

 Tactical Awareness vs Hyper Vigilance

 Lethally Armed vs Locked and Loaded at home

 Emotional Control vs Anger/Detachment
BATTLE MIND

 Mission Operational Security vs Secretiveness
 Individual Responsibility vs Survival Guilt

 Non-Defensive Combat vs Aggressive Driving

 Discipline and Ordering vs Conflict



BATTLEMIND skills are key to survival in
 combat but may lead to problems in
 when transitioning to civilian life
  Readjustment Counseling for
  Combat Veterans from
  yesterday…




Photo of
three
Soldiers
helping a
wounded
comrade
>>
 …and combat veterans of today.




Photo of
three
Armed
soldiers in
desert>>
…and their families.




     Gold Star Family   Blue Star Family
REGIONAL VET CENTERS/
VISN 21 VET CENTERS
 232Vet Centers Nationwide
 23 Vet Centers in California

 19 Vet Centers in VISN 21

 12 Vet Centers in California VISN 21

 50 Mobile Vet Centers Nation Wide




Vet Center Van >
WHAT IS UNIQUE ABOUT VETERANS
WITH TBI ?
    Cynthia Boyd, PhD
       Neuropsychologist and Co-
        Senior Scientific Director of the
        Defense and Veterans Brain
        Injury Center at Naval Medical
        Center San Diego.
       She conducts neuropsychological
        evaluations on active duty
        service members with suspected
        traumatic brain injury.

                 Defense and Veterans Brain Injury Center
                 Naval Medical Center San Diego
Military: Severe TBI

  Neuroimaging is abnormal
  Medically evacuated out of theatre

  Require intensive rehabilitation

  Unlikely to return to full duty status

  Persistent impairments in functioning




                                            Restricted to DVBIC use only
Military: Moderate TBI

  Neuroimaging is usually abnormal
  Typically evacuated out of theatre

  Less intensive rehabilitation services

  Return to duty rates are variable

  At risk for disciplinary issues, work

   performance problems, and family distress


                                      Restricted to DVBIC use only
Military: Mild TBI

    Neuroimaging is normal
      AKA   concussion
  Brief LOC or brief period of confusion
  Frequently medically managed in theatre and

   returned to duty
  Typically do not require rehabilitation

  At risk for disciplinary issues , changes in work

   performance and family discord
      Changes   may not be evident in theatre   Restricted to DVBIC use only
Blast-Related TBI

  Pathophysiology of blast-related TBI is complex
   and not fully understood
  Rapid pressure changes create shear and stress

   forces that lead to trauma such as concussion, or
   more severe TBI
  Blast waves can move objects and people,

   causing penetrating injuries or blunt trauma
  Effects of explosion are likely to be intensified

   in a confined space
                                         Restricted to DVBIC use only
Blast-Related TBI

 Blast Injuries account for
 more than 50% of
 mild TBI seen by DVBIC




                              Restricted to DVBIC use only
Physical Symptoms of TBI
             80% of all TBI’s are mild
             Dizziness

             Fatigue

             Headaches

             Impaired hearing

             Impaired vision

             Problems with balance

             Sensitivity to light

             Sensitivity to noise                       Restricted to DVBIC use only
            <<Image: Arrows going in varied directions
Cognitive Symptoms

            Impaired memory
            Trouble concentrating

            Difficulty finding words

            Slowed overall processing

            Impaired organizational and
             problem solving skills


               <<Image: Complicated Maze   Restricted to DVBIC use only
Behavioral Symptoms Reported
Following Concussion/ mTBI
            Difficulty being around
             people
            Personality changes

            Irritability, frustration, “short
             -fuse”
            May result in “acting out”
             behavior

           <<Image: Arrows going in varied directions   Restricted to DVBIC use only
Pathophysiology of mTBI/concussion

  A “neurometabolic cascade” leaves the
   brain in a state of neurophysiologic
   disarray during the acute phase after injury
  Functional Neuroimaging studies in animals
   and humans have demonstrated the brain’s
   return to normal neurophysiologic
   functioning within days to weeks
  mTBI is a transient process followed by
   spontaneous recovery               Restricted to DVBIC use only
Education

  To address misperceptions about the
   course of recovery
  Compensatory strategies

  Normal vs. abnormal changes in behavior

      Irritability
      Domestic   Violence



                                    Restricted to DVBIC use only
Symptoms of PTSD & TBI

               PTSD                        TBI
   Flashbacks         Cognitive Deficits    Headache
   Avoidance            Irritability        Sensitivity to light or
                                            noise
   Hyper vigilance      Insomnia
                                            Nausea
   Nightmares           Depression
                                            vomiting
   Re-experiencing      Fatigue
                                            Vision Problems
   phenomenon
                        Anxiety
                                            Dizziness

                                                    Restricted to DVBIC use only
Symptoms Not Shared Between
Concussion and PTSD
    Concussion
      Headache
      Dizziness/vertigo/balance      problems
      Reduced    alcohol tolerance
      Sensitivity to light & noise

    PTSD
      Flashback/  intrusive memories
      Increased startle response
      Hypervigilance


                                                 Restricted to DVBIC use only
Co-morbid Complications


    TBI                        PTSD




    Substance   Chronic
    Alcohol               Medication
                 Pain
     Abuse
                             Restricted to DVBIC use only
Important Facts

  Blast exposure does not equal TBI
  Exposure to trauma does not equal PTSD

  Multiple deployment increase vulnerability
   for blast and trauma exposure
  Multiple concussions increase vulnerability to
   persistent impairment and longer recovery
  TBI and co-existing psychiatric disorders
   interact to result in worse outcome
                                       Restricted to DVBIC use only
Future Concerns

  Adjustment to civilian life
  Occupational concerns

  Self-medication

  Irritability associated with both brain
   injury & PTSD can lead to aggression
      Increases   the probability of violent behavior
    What services are available to address
     these concerns
                                              Restricted to DVBIC use only
THE ROLE OF SOCIAL WORK AND
CARE MANAGEMENT
    Laura Gomez, LCSW
        OEF/OIF/OND Program Manager
         for the Department of Veteran
         Affairs Palo Alto Care System
        Ms. Gomez provides care
         management for the severely
         injured veterans in this healthcare
         system.
        Laura assists in transitioning
         active duty and recently
         discharged veterans into the VA
         Healthcare system.


                   VA Palo Alto Health Care System
Optimal Post Combat
33


      Provide an easy, single point of entry for care
      Honor & acknowledge veteran’s combat service

      Provide “One stop shopping” for physical,
       psychosocial, and mental health assessment
      Help to de-stigmatize mental health care

      Develop clinical expertise in post-combat care

      Provide coordination of care
Who are the OEF/OIF/OND Veterans?
  Since October 2001,
   approximately 2.04
   million U.S. troops
   have been deployed
   to OEF/OIF/OND
   conflicts
  34% of combat
   veterans have been
   deployed 2-4 times
   (9-16 months)           ^ Photo of 6 active duty military
  Veteran’s ages          men in a tent
   range from 18 years
   of age to 65, with an   << Department  of Defense: Defense Manpower
   average age of 24       Data Center. (2008)
                           VHA, Office of Public and Environmental
   (41.7%).                Hazards. (May 2008)
Demographics of OEF/OIF Vets?
                VHA Office of Public Health and Environmental Hazards February 2010 (through 4th Quarter FY09



                                                                         % OEF/OIF Veterans
                Demographics                                               (n = 508,152)
 Sex                           Male                                              88.1 %
                               Female                                             11.9%
 Birth Year Cohort             1980 – 1993                                        41.7%
                               1970 – 1979                                        27.9%
                               1960 – 1969                                        22.0%
                               1950 – 1926                                         8.4%
 Branch                        Air Force                                          12.1%
                               Army                                               62.2%
                               Marine                                             13.3%
                               Navy                                               12.3%
 Unit Type                     Active                                             53.5%
                               Reserve/Guard                                      46.5%
Role of OEF/OIF/OND Case Managers
36

      Meet with veterans
      Complete psycho-social assessment
      Provide educational materials regarding
      resources and coping strategies
      Determine the need for seriously ill or injured
      care management
      Determine if intense case management needed
      for the non-severely injured
      Ensure veterans have contact information for
      the OEF/OIF/OND team for future reference
What is Case Management?
37

        Case management
          Key in that it is the RELATIONSHIP that provides the
           support and encouragement to returning veterans
        “Medical mentoring:
          Explain the need for certain treatment approaches
           and being sensitive to the veteran’s personal style
           and the need for his buy-in
        Collaborating with the patient’s treatment team
         providers throughout the healthcare system
What is Case Management?
38

        Assists with applying or accessing service
          Connection benefits
          GI Bill
          Voc Rehab
          Social Security benefits
          DoD or Community grants
        Collaborate with the legal system to engage returning
         combat veterans into treatment and assist veterans that
         have served sentences back into society
        Collaborate with VA and Community Providers
        Appointment coordination
        Resolving VA billing issues
How case management can help …
39


      Manage multiple consults and/or no-shows
      Assist with structure in personal or family life
      Manage multiple contacts through same day
       clinic or ER
      Manage multiple mental health issues &
       suicidal ideation
      Vocational challenges
      Educational challenges
VA Collaborators
40


        Polytrauma Rehabilitation Center (PRC): Inpatient
         Acute Care
        Polytrauma Transitional Rehabilitation Program
         (PTRP): Residential/Outpatient Day Program
        Polytrauma Network Site (PNS): Outpatient Evaluative
         Clinic
        Vet centers
        Women’s Trauma Recovery Program (WTRP)
        Men’s Trauma Recovery Program (MTRP)
        OEF/OIF/OND Family Program
VA/DoD Collaborators
41


      State Department of VA Affairs
      Military One Source (DoD)

      The Army Wounded Warrior (AW2) Program

      State National Guard Program – Transition

       Assistance Advisors: list located at
            http://oefoif.vssc.med.va.gov/Communications/Pages/d
             efault.aspx
Veteran Resources
42


        Coming Home Project:
         www.cominghomeproject.net/
      The Pathway Home: www.thepathwayhome.org
      Vets4Vets: info@vets4vets.us

      Operation Purple Family Retreats:
         www.Militaryfamily.org/our-programs/operation-
         purple
        Marin Services for Women:
         www.arineserviceforwomen.org
        Swords to Plowshares: www.stp-sf.org
VA SIERRA PACIFIC NETWORK
OEF/OIF/OND Program Managers
   Laura Gomez, Palo Alto OEF/OIF Program
    650.493.5000 X60007
   Katie Debus, Livermore OEF/OIF Case Manager at
    x35393
   Paul Symmonds, Mod/Sonora OEF/OIF Case
    Manager at 42622
   Oona Houston, Livermore OEF/OIF Case Manager
    at x35495
   Raquel Morales, San Jose/Mont OEF/OIF Case
    Manager at x77629
   San Francisco VA Medical Center
    Carrie Bancroft, LCSW
    (415) 221-4810, x4405
VETERAN OUTREACH
STAND DOWNS AND COLLABORATIVE
    Chris Lopez
       Former Readjustment Counseling

        Specialist with the U.S.
        Department of Veterans Affairs.
       U.S. Army veteran infantryman,

        medically retired after he was
        wounded with a TBI and back
        injury in Iraq in a fire fight.
       Chris is on the CCCIL TBI Advisory

        Committee
Contacting and Networking

    Goal: To create a working network
     of contacts within and outside the
     Veteran Affairs in order to provide a
     continuum of care.
Networking within the VA system:

    Outlining all of the veteran service
     providers within your catchment area.
      Veteran   Centers and Veterans Hospitals.
    Establish contact with directors, public
     affairs officers, and outreach
     coordinators.
Veteran Service Office Groups:

  VFW’s – Veterans of Foreign Wars
  American Legions

  DAV - Disabled American Veterans

  Military Order of the Purple Heart

  Veteran Service Offices
Outside Contract Services:

  Family Readiness Program Workers
  Individual Unit Readiness workers in
   catchment area
  Family Assistance Network Coordinators
   (1-800-449-9662)
Military Organizations:

  Contact local National Guard Command Staff
  Family Readiness Program workers

  Retention Officers

  Local Recruiting Stations/Reserve Centers

  Career Counselors (Naval and Marine Corps)

  Transitional Assistance Programs “Taps”
   Coordinators
      Clearingbriefs for active duty soldiers being
      released from duty.
Military Special Interest Organizations:
  Militaryonesource.com (1-800-342-9647)
  Joint Support Operation Center (1-888-774-1361)

  Stand Downs:

      Created  to work with homeless veterans of any era
      that are in need of assistance.
      http://www.nchv.org/page.cfm?id=122
    Local and Statewide Collaborative.
      Designedto bring share resources together in an
      environment
      http://www.militaryconnection.com/pdfs/mary-ellen-
      commendation.pdf
A List of Resources to Seek Out Veterans:

  National Guard Units
  Reserve Units

  Transitional Assistance Programs

  Family Readiness Meetings

  Special Events

  VSO’s – Veterans Service Organizations

  Colleges
A List of Resources to Seek Out Veterans:

  National Cemeteries
  Contacting Ombudsman

  Key Wife’s Networks

  Special Interests Groups

  Red Cross

  EDD – Employment Development Department

  Employers Associations

  Mental Health Groups

  Goodwill
Conclusion:

  Remember one thing, it never hurts to ask!
  Thank you for your time and patience, if
   anyone has any questions please do not
   hesitate to ask.
Regional Veteran Services and Needs
Question 1
    Can you give a timeline of your military
     experience:
     Time in service
     When you were injured
     Discharge
Regional Veteran Services and Needs
Question 2
    As a veteran, how has having a TBI
     affected you?
      Personally
      Servicesyou have received
      Reintegrating into the community
Regional Veteran Services and Needs
Question 3
    What are the barriers to receiving services
     unique to you as both a veteran and
     person with a brain injury?
Regional Veteran Services and Needs
Question 4
    What message would you want to give
     service providers about best connecting to
     veterans returning from OEF/OIF/OND
     who may have a TBI, PTSD or multiple
     disabilities?
California TBI Resources
   CA|TBI California Traumatic Brain Injury
     www.catbi.org
   Traumatic Brain Injury Services of California
     www.tbisca.org
   Defense and Veterans Brain Injury Center
     www.dvbic.org
   Brain Line
     www.brainline.org
   Brain Injury Association of California
     www.biacal.org
   Centre for Neuro Skills
     www.neuroskills.com
Q & A AND WRAP UP

 q Questions and Answers
 q Project outreach and lessons learned

 q Where to go from here

 q Upcoming Webinars

    Maximizing Community Resources for People with
    TBI – June 2011
 q   Thank You!

				
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