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JANUARY/FEBRUARY 2011 :: 72(1)
Behavioral Health Needs of Military Personnel and Their Families

The policy forum of this issue addresses the behavioral health needs of North Carolina service members, veterans, and their families. Also in this issue, a leading pharmaceutical company reviews how its efforts complement health reform, and original articles investigate secondhand-smoke exposure, smoking among adolescents, and characteristics of cancer survivors.


Initiatives to Improve Access to Behavioral Health Services in the Veterans Affairs Health System

Harold Kudler, Kristy Straits-Tröster, Mira Brancu

N C Med J. 2011;72(1):40-42.PDF | TABLE OF CONTENTS

In response to veterans’ needs in the context of recent deployments, the Veterans Affairs (VA) health system has increased the number of its facilities and caregivers and has pioneered changes in policy and programs. We review significant recent initiatives to improve access to behavioral health services in the VA health system.

Individuals who have served in the armed forces of the United States may be eligible for a broad range of programs and services provided by the US Department of Veterans Affairs (VA) [1]. The VA operates the nation’s largest integrated health care system, with more than 1,400 sites of care, including VA medical centers, community-based outpatient clinics, community living centers, domiciliaries, readjustment counseling centers (also known as Vet Centers), and various other facilities [2].

As of the end of September 2010, 1,250,663 Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans had left active duty and become eligible for VA health care. Roughly half (625,384) of these veterans have had at least 1 episode of VA health care since September 2002. The fact that 50% of eligible OEF/OIF veterans have already received VA health care is impressive, given that, of the 22.7 million living US veterans, only 8.1 million (36%) were enrolled in VA health care as of September 2009, and only 5.7 million (25%) had used VA health care in the preceding 12 months [3].

The VA health system has grown rapidly in response to the needs of American veterans, but simply increasing the number of facilities and clinicians will not meet the needs of eligible veterans—changes in policy and program are also required. This commentary reviews a selection of significant initiatives undertaken by the VA to improve access to behavioral health services.

New Regulations on Posttraumatic Stress Disorder (PTSD) Claims
Perhaps the most important barrier to accessing care for PTSD had been the level of evidence required of a veteran to corroborate the occurrence of a significant traumatic stressor. In July 2010, the VA published a new regulation designed to make access to care and the claims process easier for veterans whose trauma was related to fear of hostile military or terrorist activity and was consistent with the places, types, and circumstances of the veteran’s service [4]. Under the new rule, the VA does not require corroboration of a PTSD stressor if a VA psychiatrist or psychologist confirms that the reported event adequately supports a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor. The VA will continue to seek verification from the Department of Defense (DoD) that an individual served in an area of combat operations. This rule applies to veterans of every era.

Rural Health
Veterans are less likely to access services that are difficult to reach, and this is as true for young veterans with new injuries as it is for older veterans with compromised health. Rural veterans, in particular, often face obstacles of distance, poor-quality roads, lack of public transportation, and, sometimes, cultural obstacles as they seek to engage the services they have earned. Recognizing this problem, the VA created the Office of Rural Health (ORH), which has provided $215 million in competitive funding to improve services specifically designed for veterans in rural and highly rural areas across the nation.

More than half of all veterans in North Carolina are classified as living in rural or highly rural areas, according to federal definitions. The VA’s Mid-Atlantic Health Care Network (also known as Veterans Integrated Service Network Number 6 [VISN 6]), which includes North Carolina, Virginia, and sections of South Carolina and West Virginia, will receive more than $20 million in VA rural health funds in fiscal year 2011. ORH funding has allowed VISN 6 to establish new outpatient clinics, expand collaborations with federal and community partners, accelerate the use of telemedicine, and explore innovative uses of technology, to better serve rural veterans.

One VISN 6 innovation is the development of rural health teams at each VISN 6 VA medical center. In North Carolina, the teams are located in Asheville, Durham, Fayetteville, and Salisbury. These multidisciplinary teams travel the state to meet new veterans and their families, educate them about VA services, enroll them (on the spot, by use of wireless computer links, whenever possible), and schedule appointments for any needed treatment. The teams include nurse health educators, who lead classes on management of high-risk health problems, like diabetes or chronic pain; social workers, who can immediately connect veterans and their families with needed services, including assistance for homeless veterans; pharmacists, who review veterans’ medications and help reconcile their VA prescriptions with any medications received from local clinicians; and public affairs officers, who engage local media, community leaders, and stakeholders to ensure maximum awareness of each VISN 6 rural health team’s efforts.

VISN 6 is also developing a Rural Connections Knowledge Repository, which will support rural health care clinicians through a Web-based introduction to VA services and a comprehensive guide to evidence-based best practices, including VA/DoD clinical practice guidelines for PTSD, traumatic brain injury, and other disorders. The repository is designed to equip rural clinicians with high-quality information and tools, including links to VA services and specialty care, when needed.

The goal of the VISN 6 rural health program is to complement community services, rather than to compete with them. Rural America has a strong culture typified by both self-sufficiency and volunteerism. On the other hand, rural veterans often have qualms about stepping outside their own communities to seek care, even if they are eligible for VA care. By helping veterans, their families, their clinicians, and the local community learn about the range and quality of VA services and better understand the needs of rural veterans and their families, the rural health program seeks to enhance access to care and quality of care, whenever and wherever veterans choose to seek it.

Helping Homeless Veterans
The VA has undertaken a campaign to end veteran homelessness by 2015, with broad support at the federal, state, and local levels, in both the public and the private sectors. At the time of this writing, the VA’s partnership with the Department of Housing and Urban Development has secured permanent housing, with dedicated case managers and access to VA health care, for more than 18,000 veterans [5]. This homelessness program is unusual in that it provides housing for members of the veteran’s household, as well.

To maximize access, the VA created a national homeless hotline (1-877-4AID VET or 1-877-424-3838). During 2010, the VA’s homeless-outreach coordinators assisted almost 7,800 homeless veterans in filing for disability pay or pensions and assisted nearly 100,000 veterans and family members.

Whenever possible, the VA acts to prevent homelessness. One of its newest prevention tools is the Supportive Services for Veteran Families program, which provides supportive services to very-low-income veterans and their families who are in or are transitioning to permanent housing. The VA awards grants to private nonprofit organizations and consumer cooperatives that assist very-low-income veterans and their families by providing a range of supportive services designed to promote housing stability.

Because homelessness, especially when combined with mental health problems, frequently leads to incarceration, the VA established the Veteran Justice Outreach (VJO) initiative, which ensures that eligible veterans involved in the justice system have timely access to VA mental health and substance abuse services when clinically indicated, and other VA services and benefits as appropriate. VJO is designed to avoid the unnecessary criminalization of mental illness and the extended incarceration among veterans. The Health Care for Re-entry Veterans program addresses community reentry of incarcerated veterans by preventing homelessness; reducing the impact of medical, psychiatric, and substance abuse problems on community readjustment; and decreasing the likelihood of re-incarceration for those leaving prison.

Because homelessness among veterans is such a complex issue, the VA has developed the National Center on Homelessness Among Veterans as a forum to exchange new ideas and provide education and consultation, to improve the delivery of services, and to disseminate the knowledge gained through the efforts of the center’s research and model-development cores to the VA, other federal agencies, and community provider programs that assist homeless populations. In the coming months and years, this center will provide important opportunities for collaboration with state and local leaders and homelessness programs across North Carolina.

Suicide Prevention
The VA recognizes the risk of suicide among veterans and has established a suicide-prevention hotline (1-800-272-TALK or 1-800-272-8255). Since the beginning of operations, in July 2007, more than 400,000 calls have been received, and the VA’s suicide prevention program (which also includes dedicated suicide prevention coordinators at VA facilities across the nation) has been credited with saving more than 10,000 veterans [6].

Families at Ease
In the course of a series of focus groups composed of OEF/OIF veterans and spouses living within 60 miles of Raleigh, North Carolina, Straits-Tröster and her team from the VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC) noted persistent family concerns about irritability, sleep problems, social withdrawal, rapid changes in family roles and responsibilities, and lack of communication among veterans after deployment [7]. Each of these factors contributes independently and collectively to family stress and threatens family breakup. Veterans and spouses most desired VA services related to anger management, marital and family counseling, stress management, benefits counseling, and career and school counseling. They identified the stigma associated with reporting mental health problems, their own pride and fear of betraying any sign of “weakness,” the potential negative impact of seeking help on the chances for promotion, and “red tape” as key barriers to seeking assistance.

In recognition of the impact that deployment-related stress can have on families, the VISN 6 MIRECC has piloted the Families at Ease program in North Carolina [8] and is in the process of rolling out a national Families at Ease program, in collaboration with VISN 3 (based in Philadelphia, PA) and the VA Office of Mental Health Services. This program helps family members cope with their veteran’s postdeployment difficulties and supports the family’s efforts to find help for the veteran. It provides referrals for veterans and their family members and coaches family members in motivating their veteran to seek help. Families at Ease can be reached by phone at 1-888-823-7458, or by e-mail at

Meeting the Needs of Women Veterans
Women compose 8% of all veterans and more than 11% of all OEF/OIF veterans. More than half of all women OEF/OIF veterans have already enrolled for VA health care [9]. The VA is expanding its comprehensive approach to women’s health, including (but not limited to) primary care, gender-specific health-promotion and disease-prevention programs, hormone-replacement therapy, breast and gynecological care, maternity and limited infertility treatment (excluding in vitro fertilization), acute medical and surgical care, telemedicine, emergency care, substance abuse treatment, mental health care, homebound care, rehabilitation services, and long-term care. VA has trained more than 500 clinicians in care specific to women veterans, and VA researchers are actively conducting medical research on women’s health across the nation.

This brief summary provides only a glimpse of the VA’s efforts to improve access to behavioral care and related health services across its national system. In concluding, we note that one of the best ways to improve the care of veterans is to ensure that clinicians outside of the VA have a good understanding of what the VA offers, appreciate the quality of VA services, feel comfortable accessing these services, and become full partners in coordinating federal, state, and community systems of care in the service of veterans and their families, who have served us all so well.

Financial support. Department of Veterans Affairs (grant to the VISN 6 Mental Illness Research, Education, and Clinical Center).

Potential conflicts of interest. All authors have no relevant conflicts of interest.

1. Department of Veterans Affairs (VA). Federal Benefits for Veterans, Dependents, and Survivors. Washington, DC: VA; 2010. Accessed April 10, 2011.

2. Department of Veterans Affairs Web site. Accessed April 10, 2011.

3. Office of Public Health and Environmental Hazards, Department of Veterans Affairs (VA). Analysis of VA Health Care Utilization Among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans. Washington, DC: VA; December 2010.

4. Office of Public Affairs, Department of Veterans Affairs. VA simplifies access to health care and benefits for veterans with PTSD [press release]. Released July 12, 2010. Accessed April 10, 2011.

5. Homeless veterans. Department of Veterans Affairs Web site. Accessed April 10, 2011.

6. Mental health: suicide prevention. Department of Veterans Affairs Web site. Accessed April 10, 2011.

7. Straits-Tröster KA, Gierisch JM, Calhoun JS, Strauss JL, Voils C, Kudler H. Living in transition: veterans’ perspectives on the post-deployment shift to civilian and family life. In: Kelly D, Howe-Barksdale S, Gitelson D, eds. Treating Young Veterans: Promoting Resilience Through Practice and Advocacy. New York, NY: Springer Publishing; 2011.

8. Families at Ease. Department of Veterans Affairs Web site. Accessed April 10, 2011.

9. Women veterans health care. United States Department of Veterans Affairs Web site. Accessed April 10, 2011.

Harold Kudler, MD associate director, VISN 6 Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, and Duke University, Durham, North Carolina.

Kristy Straits-Tröster, PhD, ABPP assistant director, VISN 6 Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, and Duke University, Durham, North Carolina.

Mira Brancu, PhD clinical psychologist and managing director, VISN 6 Registry Project, Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, and Duke University, Durham, North Carolina.

Address correspondence to Dr. Harold Kudler, VISN 6 MIRECC (116A), Durham VA Medical Center, 508 Fulton St, Durham, NC 27705 (