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					   VA Update on Psychological Health
       and TBI Clinical Initiatives

Sonja V. Batten, Ph.D.
Acting Deputy Director
Defense Centers of
Excellence for
Psychological Health
and TBI                     November, 2008


• VACO Rehabilitation Services
• Han Kang

          Current DoD Roster of Recent
          War Veterans

• Over 1.6 million service members have served in OEF/OIF to date

• Latest Update of roster for veterans
    – Provided to Dr. Kang, Veterans Health Administration (VHA)
      Environmental Epidemiology Service, on May 2, 2008

• Qualifications of DoD’s OEF/OIF deployment roster
    – Contains list of veterans who have left active duty and does not include
      currently serving active duty personnel
    – Does not distinguish OEF from OIF veterans
    – Roster only includes separated OEF/OIF veterans with out-of-theater
      dates through February 2008
    – 4,271 veterans who died in-theater are not included

     Updated Roster of OIF and OEF
     Veterans Who Have Left Active Duty

• 868,717    OEF and OIF veterans who have left
             active duty and become eligible for
             VA health care since FY 2002

  – 50% (437,873) Former Active Duty troops
  – 50% (430,844) Reserve and National Guard

      VA Health Care Utilization for FY 2002-2008
      (2nd QT) by Service Component

• Among all 868,717 separated OEF/OIF Veterans
   – 40% (347,750) of total separated OEF/OIF veterans have
      obtained VA health care since FY 2002 (cumulative total)

• 437,873 Former Active Duty Troops
   – 41% (179,475) have sought VA health care since
             FY 2002 (cumulative total)

• 430,844 Reserve/National Guard Members
   – 39% (168,275) have sought VA health care since
             FY 2002 (cumulative total)

    Comparison of VA Health Care

The cumulative total of 347,750 OEF/OIF
veterans evaluated by VA over approximately
6 years from FY 2002 through FY 2008 (2nd QT)
represents about 6% of the 5.5 million
individuals who received VHA health care in
any one year (total VHA patient population of
5.5 million in 2007).

Demographic Characteristics of OEF and
OIF Veterans Utilizing VA Health Care

                             % OEF/OIF Veterans
                                 (n = 347,750)
                 Male                    88
                 Female                  12
     Age Group
                 <20                      7
                 20-29                   51
                 30-39                   23
                 ≥40                     18
                 Air Force               12
                 Army                    64
                 Marine                  13
                 Navy                    11
     Unit Type
                 Active                  52
                 Reserve/Guard           48
                 Enlisted                92
                 Officer                  8

              Frequency of Possible Diagnoses Among
              OEF and OIF Veterans

Diagnosis                                                                                                (n = 347,750)
(Broad ICD-9 Categories)                                                                                          Frequency *            %

Infectious and Parasitic Diseases (001-139)                                                                          40,956           11.8
Malignant Neoplasms (140-208)                                                                                          3,248           0.9
Benign Neoplasms (210-239)                                                                                           13,910            4.0
Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279)                                                       75,850           21.8
Diseases of Blood and Blood Forming Organs (280-289)                                                                   7,675           2.2
Mental Disorders (290-319)                                                                                          147,744           42.5
Diseases of Nervous System/ Sense Organs (320-389)                                                                  121,473           34.9
Diseases of Circulatory System (390-459)                                                                              56,900           16.4
Disease of Respiratory System (460-519)                                                                               71,087          20.4
Disease of Digestive System (520-579)                                                                                110,449          31.8
Diseases of Genitourinary System (580-629)                                                                             37,118         10.7
Diseases of Skin (680-709)                                                                                             55,797          16.0
Diseases of Musculoskeletal System/Connective System (710-739)                                                       165,439           47.6
Symptoms, Signs and Ill Defined Conditions (780-799)                                                                 138,043           39.7
Injury/Poisonings (800-999)                                                                                           73,767           21.2
*These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2008; veterans can have multiple
 diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple
 categories, so the above numbers add up to greater than 347,750.

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

Disease Category (ICD 290-319 code)                                               Total Number of
                                                                                  GWOT Veterans**
PTSD (ICD-9CM 309.81)+                                                                             75,719
Depressive Disorders (311)                                                                         50,732
Neurotic Disorders (300)                                                                           40,157
Affective Psychoses (296)                                                                          28,734
Nondependent Abuse of Drugs (ICD 305)++                                                            21,201
Alcohol Dependence Syndrome (303)                                                                  12,780
Special Symptoms, Not Elsewhere Classified (307)                                                   7,685
Sexual Deviations and Disorders (302)                                                               7,076
Drug Dependence (304)                                                                               5,764
Specific Nonpsychotic Mental Disorder                                                               4,654
   due to Organic Brain Damage (310)+++
*   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 the diagnosis is “rule-out” or provisional, pending further evaluation.
** A total of 147,744 unique patients received a diagnosis of a possible mental disorder. A veteran may have more than one mental disorder diagnosis
    and each diagnosis is entered separately in this table; therefore, the total number above will be higher than 147,744.
+   This row of data does not include information on PTSD from VA’s Vet Centers or data from veterans not enrolled for VHA health care. Also, this row
    does not include veterans who did not receive a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment reaction (ICD-9 309).
++ This category currently excludes 39,811veterans who have a diagnosis of tobacco use disorder (ICD-9CM 305.1) and no other ICD-9CM 305
+++ The total number of GWOT veterans with a possible diagnosis of “specific nonpsychotic mental disorder due to organic brain damage (310),” which
    includes postconcussion syndrome, exceeds the total number of diagnoses for “acute reaction to stress (ICD-9 CM, 308)” for the second quarter FY
    2008 report as compared to the previous report for first quarter FY 2008 released in May 2008.

Mental Health Services in VA:
Initiatives and Current Status

        MH Strategic Plan
        Adopted 2004

• Implement President’s New Freedom Commission on MH
  Report within VA
• Principal components:
   –   Expanding access and capacity
   –   Integrating MH and primary care
   –   Transforming system to focus on recovery & rehabilitation
   –   Implementing evidence-based care
   –   Returning veterans
   –   Suicide Prevention

          MHSP Implementation

• Over $850 million invested since FY05 in specific Mental
  Health Enhancement Initiatives (MHEI)
• Increasing basic MH funding, e.g., over $3.2 billion total
  for mental health services in FY08
• Over $530 million in proposed VA MHEI budget for FY09
  and over $3.8 billion in basic funding
• Over 3,900 new mental health staff hired since FY 2005;
  total mental health staff in the system almost 17,000

          Basic Mental Health Programming

• Programs available before Mental Health Initiatives – have
  stayed the same or grown in capacity
   –   Outpatient specialty mental health clinics
   –   Inpatient psychiatry programs
   –   Residential Rehabilitation treatment programs
   –   Substance Use Disorder care
   –   Vocational Rehabilitation
   –   Specialty PTSD programs
   –   Local initiatives
• Programs that have declined
   – Day Hospital
   – Sheltered Workshop

    PTSD and OEF/OIF Programs

• Expanded PTSD points of care

• PTSD Mentoring program

• SeRV-MH teams for returning OEF/OIF
  – 95 teams

     VA Dissemination of ESTs

• Passive dissemination of guidelines (e.g., printing
  guidelines) is often ineffective
• Three current VA dissemination initiatives (2 more
   – Prolonged Exposure for PTSD
   – Cognitive Processing Therapy for PTSD
   – Acceptance and Commitment Therapy for
     Depression and Associated Anxiety Symptoms
• OMHS leadership supports need to train clinicians
  AND develop internal resources to continue training
  over time
   – Self-sustaining
     Addressing Barriers: Building
     Practitioner Support
• Dissemination is unlikely to succeed if changes are
  only initiated “top down”
   – Problems with previous efforts at dissemination may
     have been their unidirectional nature
   – Emphasis on changing practitioner behavior as decided
     by researchers or administrators

     Addressing Barriers: Training

• Training/Supervision designed to remedy skills
  deficits and attitudinal obstacles
   – Training will be adequate in intensity
   – Training will include effective change methods (e.g.,
     modeling, role play, feedback, homework)
   – Trainees will see two cases under weekly supervision
   – Trainees will commit to use the therapy in which they
     are trained, supervise others

     Enhanced Access and Continuity of Care

• 24/14 requirement for new mental health
• Expanded clinic hours
• Required follow-up of missed appointments
• Requirement for MH in Emergency Departments
  and Urgent Care Centers

    Military Sexual Trauma

• MST Coordinator in every VA facility
• National MST Recovery Team; provides
  education and mentoring to MST coordinators
  and providers nation-wide

    Centers of Excellence

• 10 MIRECCs
• National Center for PTSD
• 3 Congressionally-mandated COEs for
  mental health (Canandaigua COE with
  suicide prevention focus is one)
• VA collaboration with Defense Centers of
  Excellence for Psychological Health and TBI

         Suicide Prevention

• Suicide Prevention Coordinator in each medical center
• Centers of Excellence
• National programs for education and awareness
• 24/7 Hotline, in conjunction with SAMHSA suicide prevention hotline

   – Option directs Veterans to a VA professional with access to Electronic
     Medical Record
   – Hand-off to local Suicide Prevention Coordinator for follow-up and
     ongoing care

       Mental Health Services in Polytrauma

• MH team in every Level 1 Polytrauma Center
• MH staff on VISN level Polytrauma teams
• MH staff in Transitional Living programs for
  Polytrauma patients

VA’s Polytrauma System of Care &
TBI Screening


• Two or more injuries to physical regions or organ
systems, one of which may be life threatening,
resulting in physical, cognitive, psychological, or
psychosocial impairments and functional disability.
• TBI frequently occurs in polytrauma in combination
with other disabling conditions (e.g., amputation,
auditory and visual impairments, SCI, PTSD, other MH
• Brain injury is the impairment that primarily guides
the course of the rehabilitation.
                                   VHA Handbook 1172.1

      VA Polytrauma System of Care
• Integrated system of care with over 100 specialized
  rehabilitation sites distributed across the country
• Services delivered by interdisciplinary teams of
  rehabilitation specialists and medical consultants
• Brain injury drives the care
• Advanced rehabilitation practices and equipment
  with focus on independence and community re-
• Emphasis on care coordination and case
• Provide life-long care and access to a continuum of
• Polytrauma Telehealth Network

     Implementation of the VA
     Polytrauma System of Care

                                           April 07: TBI Screening

                                 March 07:
                                 80 Polytrauma Support Clinic Teams,
                                 50 Polytrauma Points of Contact

                     July 06: Polytrauma Telehealth Network

              December 05: 22 Polytrauma Network Sites

       February 05: Four Polytrauma Rehabilitation Centers

1992: VHA TBI Lead Centers Selected
          PSC Components

Polytrauma Centers (4+)             Goal: Get Home
Regional referral centers

Polytrauma Network Sites (22)
   VISN level referral sites

            Polytrauma Support Clinics (80)
                  Facility level teams

                        Polytrauma Points of Contact (50)
                         Referral and care coordination
Polytrauma Rehabilitation Centers

  Richmond           Tampa

   Palo Alto        Minneapolis
          Polytrauma Rehabilitation Centers

• Regional referral centers for veterans and active duty
    service members with TBI and polytrauma
•   Patients with high degree of medical complexity and
    varied patterns of disabling injuries
•   Full range of acute comprehensive medical and
    rehabilitative services
     – Comprehensive acute interdisciplinary inpatient rehabilitation
     – Comprehensive interdisciplinary inpatient evaluations
     – Emerging Consciousness Program
     – Residential Transitional Rehabilitation Program
• Leadership in education, research and program development
          Polytrauma Network Sites

• One PNS located in each VISN (+ San Juan)
• Interdisciplinary, specialized post-acute rehabilitative
  services (inpatient and outpatient)
• Develop and manage rehabilitation plans for veterans and
  active duty service members with TBI and polytrauma
• Serve as resources and coordinate services for TBI and
  polytrauma across the VISN
• Develop and conduct VISN level educational programs for
  providers as well as patients and families in the areas of
  polytrauma and TBI
• Provide leadership for tracking VISN level outcome data
  and performance monitors for polytrauma and TBI.
      Role of the Polytrauma Support
      Clinical Team
• Located at 80 VAMCs across VHA
• Primary role
   – Specialty rehabilitation care closer to home
   – Evaluation, development of a treatment plan,
     interdisciplinary rehabilitation care, and long-term
     management of patients with on-going or changed
     rehabilitation needs
   – Nursing and social work care managers coordinate clinical
     and support services for patients and their families
• Lead role
   – Conduct comprehensive evaluations of patients with positive
     TBI screens and develop rehabilitation and community re-
     integration plans

     Polytrauma Points of Contact

• Designated in March, 2007 at 50 Medical
  Centers without specialized rehabilitation teams
• VA staff member knowledgeable of Polytrauma
  System of Care
• Case management and referral to Polytrauma
  System of Care
• Community Based Outpatient Clinic
• VA contact close to home
• Coordinate services provided within community
         Long Term Follow-up

• Some symptoms are lifelong and require
  special expertise
• Emerging complications
• Changes in developmental stage
• Changes in social situation
• New treatments or technology
• Tune-ups
• Support and connectivity
• Aging with disability
• Scheduled and as needed (patients, families
  may not always be proactive)                  33
A New Era of VA Care