Providing Mental Health, Substance Abuse, and CoOccurring Disorders Services for Returning Veterans

1
Providing Mental Health, Substance Abuse, and
Co-Occurring Disorders Services for Returning
Veterans and Their Families
Ruby V. Neville, MSW, LGSW Policy Lead on
Returning Veterans Families Center for
Substance Abuse Treatment Substance Abuse and
Mental Health Services Administration U. S.
Department of Health and Human Services
2

• Americans enjoy the finest health care in the
  world. Our challenge is to make the care more
  affordable and ensure that everyone has access to
  health care.

              Michael O. Leavitt Secretary of the
U.S. Department of Health and Human Services
3
Terry L. Cline, PhDAdministratorSubstance Abuse
and Mental Health Services Administration

• We have a moral obligation to marshal resources
  to address the challenges that our service
  members and their families are facing. 

May 2007
4
An Introduction to the Substance Abuse and
Mental Health Services Administration (SAMHSA)

• One of the eleven grant making agencies of the
  U.S. Department of Health and Human Services,
  with a budget of approximately 3 billion
  dollars.
• Website http//www.SAMHSA.gov

5
The Center for Mental Health Services (CMHS)

• Mission
• To ensure access and availability of quality
  mental health services to improve the lives of
  all adults and children in this Nation.

6
The Center for Substance Abuse Prevention (CSAP)

• Mission
• To decrease substance use and abuse by bringing
  effective substance abuse prevention to every
  community

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The Center for Substance Abuse Treatment (CSAT)

• Mission
• To improve the lives of individuals and families
  affected by alcohol and drug abuse by ensuring
  access to clinically sound,
  cost-effective addiction treatment that reduces
  the health and social costs to our communities
  and the Nation

8
Substance Abuse and Veterans

• In 2000, according to the NSDUH, 324,000 VA
  patients had substance abuse diagnoses and 2
  million reported using illicit drugs.
• More than 55,000 veterans were admitted into
  addiction treatment facilities in 2000.
• numerous studies show that the rate of alcohol
  and other drug use disorders are high among
  veterans within the VHA health care system.
  (Institute for Research, Education, and Training
  in Addictions, 2004)

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Substance Abuse and Veterans

• Alcohol is the primary substance of abuse among
  veterans (1)
• 75 of combat veterans with lifetime PTSD also
  met criteria for alcohol abuse or dependence. (2)
  
• Heroin and Cocaine are also abused

• National Survey on Drug Use and Health,2005
• (2) Saxon, et al., . (1998). Archives of General
  Psychiatry, 55913-917

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Mental Health and Co-Occurring Illness Among
Veterans

• From 2004 to 2006, 395,000 veterans had
  co-occurring serious psychological distress (SPD)
  and substance use disorder (SUD)
• Veterans aged 18 to 25 have the highest rate of
  SPD and SUD at 8.4, with veterans 55 or older
  having the lowest rate at 0.7.
• An NSDUH study found no significant difference in
  co-occurring disorders among males and females
  (1.5 vs. 2.0 respectively.)

The NSDUH Report, November 1, 2007
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Prevalence of Serious Psychological Distress
(SPD), Substance Use Disorder (SUD), and
Co-Occurring SPD and SUD in the Past Year among
Veterans 2004 to 2006
Percentage
12
Prevalence of Serious Psychological Distress
(SPD), Substance Use Disorder (SUD), and
Co-Occurring SPD and SUD in the Past Year among
Veterans, by Age 2004 to 2006
Percentage
The NSDUH Report, November 1, 2007
13
Prevalence of Serious Psychological Distress
(SPD), Substance Use Disorder (SUD), and
Co-Occurring SPD and SUD in the Past Year among
Veterans, by Gender 2004 to 2006
Percentage
The NSDUH Report, November 1, 2007
14
Prevalence of Serious Psychological Distress
(SPD), Substance Use Disorder (SUD), and
Co-Occurring SPD and SUD in the Past Year among
Veterans, by Family Income 2004 to 2006
Percentage
The NSDUH Report, November 1, 2007
15
Co-Occurring Disorders Among Homeless Veterans

• Among homeless veterans, 1/3 to 1/2 have
  co-occurring mental illnesses and substance use
  disorders.

Source Coalition for Homeless Veterans
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The Mental Health Substance Use Disorder Safety
Net

• The Department of Defense and the Department of
  Veterans Affairs are the primary providers of
  mental health and substance use disorder care for
  returning service men and women, and for
  veterans.
• Not all veterans will present for care at DoD or
  DVA related facilities. Community providers can
  support the safety net by screening and referring
  to appropriate DoD or DVA facilities or by
  providing military service informed care.

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SAMHSA AND RETURNING VETERANS

• SAMHSAs role is to ensure that mental health
  providers in the community are aware that VA
  provides ready access to high-quality mental
  health services.
• In addition to leveraging SAMHSAs existing
  resources and collaborating with DoD and VA,
  SAMHSA offers a wealth of knowledge and
  information about substance abuse and mental
  health that can inform the efforts of community
  providers attempting to assist returning veterans
  and their families.

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Which Vets does the Community Provider Have The
Potential To See?

• Vets in areas where there are no VAs
• Fee Basis Care
• Vets who are not eligible for VA services
• Vets who are not service connected and who choose
  not to pay for VA services
• Vets who have alternative insurance and who
  choose to use a community provider
• Vets (or active duty service members) who fear
  the stigma of being seen for mental health or
  substance use disorders

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Discharges Service Complications that militate
against service connected care in the VA

• Misconduct Discharges
• Pre-Existing Mental Disorders
• Depression
• Bipolar Disorder
• Pre-Existing Physical Disorders
• Misdiagnosis of Service Connected PTSD
• Depression -Substance Use Disorder
• Somatic Disorder

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Family Members of Vets

• Family members of active duty service people or
  veterans may be seen by community service
  providers
• Pre-deployment issues
• Post-deployment issues
• Children

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Veterans Their Families A SAMHSA Priority
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SAMHSA AND RETURNING VETERANS

• Returning Veterans will be included in all
  relevant announcements of grant availability, and
  applicants for SAMHSA grants will be strongly
  encouraged to address veterans issues.
• Returning veterans and their families is one of
  SAMHSAs Matrix program areas and assures
  attention to their needs over time throughout
  SAMHSAs major, ongoing programs.

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Comorbidity and Suicide

• The health conditions most consistently
  associated with suicide are mental illness,
  substance use disorders, and alcohol use
  disorders affecting up to 90 of all people who
  die by suicide.
• Typically, people in the general population who
  die by suicide are older, male, and white, and
  have depression and medical or substance abuse
  issues .

USDHHS, 2000
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Examining suicide rates using data from the VA's
National Registry for Depression

• 18 to 44 years 95.0 suicides per 100,000 PY
• 45 to 64 years 77.9 per 100,000 PY
• 65 years or older, 90.1 per 100,000 PY
• Total 0.21 percent (1,683 vets) died by suicide
  during the study observation period (1999-04).
• Kara Zivin, Ph.D., Research Health Scientist,
  Health Services Research and Development,
  Department of Veterans Affairs, House Veterans
  Affairs Committee, December 12, 2007

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SAMHSA Support Mission of DoD and VA

• Suicide Prevention Lifeline1-800-273-TALK
• July 2007, SAMHSAs collaboration with VA
  culminated in a new service to help veterans and
  their families deal with a potential suicidal
  crisis.
• In cooperation with VA, SAMHSA modified its
  toll-free National Suicide Prevention Lifeline.
• Automatically connects callers to crisis centers
  in their area.
• A new prompt offers the option of pressing 1 and
  connecting directly to a special VA suicide
  crisis line, located in Canandaigua, NY, and
  staffed by mental health professionals.

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SAMHSAs RETURNING VETERANS WEB PAGE

• A special Web page for veterans and their
  families is posted on the SAMHSA Web site at
  www.samhsa.gov/vets.
• (See Resources for Veterans)

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Mental Health Task Force

• SAMHSAs collaboration with DoD has included
  participation in the DoD Mental Health Task
  Force, which was charged with looking at the
  efficacy of behavioral health services for active
  duty members returning from Iraq and
  Afghanistan, says Ms. Power, who served as
  SAMHSAs representative on the Task Force.
• In June 2007, the groups recommendations went to
  the Secretary of Defense, who responded in
  September of that year with a blueprint for
  action. DoD asked SAMHSA to analyze resources,
  programs, and initiatives and identify those that
  can aid in meeting the recommendations of the
  Task Force.

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The result?

• A recently completed Crosswalk document
  highlights several areas where SAMHSAs expertise
  can help.

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National Forum - May 2007

• Brought together providers of community mental
  health and substance abuse services and
  representatives of veterans' service
  organizations. They provided recommendations to
  SAMHSA on how the mental health and substance
  abuse provider communities can support DoD and VA
  efforts in addressing the behavioral health needs
  of returning veterans and their families.

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State Local Providers The Safety Net of
Support No Wrong Door Policy
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No Wrong Door PolicyAmong Many State Local
Providers

• SAMHSA encourage its grantee providers to
• address the range of client needs
• wherever a client presents for care
• whenever a client presents for care
• properly refer clients for appropriate care as
  needed
• follow-up on referrals to ensure clients
  received proper care

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AN EXAMPLE OF

• A STATE PROVIDING
• COMMUNITY BASED
• TREATMENT TO
• RETURNING VETERANS

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California One of Many States Veterans Admitted
to Community-Based Programs

• In 2006 the California Department of Alcohol and
  Drug Programs reported 6,308 unique veterans were
  admitted to community-based substance abuse
  programs.
• Some of the individuals identified as veterans
  were admitted to more than one modality of
  service, increasing the admittance total to
  8,476.
• These community-based organizations were
  recipients of SAPT Block Grant funds awarded by
  SAMHSA.

Source CSAT/Division of State and Community
Assistance, 2007
34
Bay Area Veterans Admitted to Community-based
Programs

• During 2006 there were 2,317 admissions of
  veterans to community-based substance abuse
  programs within the Bay Area.

Source California Department of Alcohol and Drug
Programs, 2007
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CSAT Discretionary Programs Opportunities to
Provide Services to Returning Veterans
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(FY) 2008 Jail Diversion and Trauma Recovery
Program- Priority to Veterans Grants (CMHS)

• Designed to reach the growing number of
  individuals with post traumatic stress disorder
  and trauma-related disorders involved in the
  justice system.
• SAMHSA expects that approximately 2.475 million
  in funding will be available to award up to 6
  grants for up to 5 years.
• The average award amount is expected to be up to
  412,500 annually.
• Eligible applicants are State Mental Health
  Agencies and federally recognized American
  Indian/Alaska Native Tribes and tribal
  organizations. Consortia of tribal organizations
  are also eligible to apply.
• DUE DATE Friday, May 8, 2008.

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CSAT Grant OHIO VALLEY CENTER FOR BRAIN INJURY
PREVENTION AND REHABILITATION

• Increasing Substance Abuse Treatment Compliance
  forPersons with Traumatic Brain Injury
• a 3-year grant to Ohio State University to study
  methods of improving the ability to engage
  individuals with traumatic brain injuries in
  treatment for co-existing substance abuse
  problems.
• John D. Corrigan, PhD, is the Principal
  Investigator and Jennifer Bogner, PhD, the
  co-Principal Investigator. Co-investigators are
  Dennis Moore Ed.D, from the SARDI Project at
  Wright State University, and Allen Heinemann PhD,
  from the Rehabilitation Institute of Chicago.

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The Access to Recovery (ATR) Voucher Program

• Part of a Presidential initiative to provide
  client choice among substance abuse clinical
  treatment and recovery support service providers,
  expand access to a comprehensive array of
  clinical treatment and recovery support options
  (including faith-based programmatic options), and
  increase substance abuse treatment capacity.

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ATR Recovery Support Services

• Transportation
• Employment  services or job training
• Case management
• Housing assistance or services
• Child care
• Family, marriage counseling, and education
• Peer-to-peer services,
• mentoring,
• Coaching
• Life skills
• Spiritual and faith-based support
• Education

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Missouri's Access to Recovery II

• Awarded approximately 14.5M over three years
• A broad spectrum of people will be served, but
  priority will be given to critical populations
  including veterans returning from Iraq and
  Afghanistan

41
SAMHSA/CSAT Programs Addressing Veterans Needs

• New Directions North is a residential
  rehabilitative center for providing integrated
  treatment services to veterans in Los Angeles
  County who are homeless and suffering from
  co-occurring mental illness and chronic substance
  abuse disorders
• Serving Children and Adolescents In Need, Inc.,
  Laredo, TX, provides substance abuse residential
  and outpatient treatment services to returning
  veterans.
• Robert Wood Johnson Medical School, New Jersey,
  implements a program for homeless veterans with
  co-occurring addiction and mental illness to
  implement a comprehensive substance abuse and
  mental health service system

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• CSATs Division of Pharmacologic Therapies
• Medication Assisted Treatment (MAT)

• Buprenorphine Physician and Treatment Program
  Locator
• Locates physician(s) and treatment program(s)
  authorized to treat opiod addiction with
  Buprenorphine.
• Potential to assist returning veterans from Iraq
  and Afghanistan with opiod addiction/disorders.
• Website http//buprenorphine.samhsa.gov/bwns_loca
  tor/index.html

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Substance Abuse Treatment Facility Locator

• This searchable directory of 11,000 addiction
  treatment programs includes residential treatment
  centers, outpatient treatment programs, and
  hospital inpatient programs for drug addiction
  and alcoholism (adolescents/adults).
• Website http//dasis3.samhsa.gov/

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Enhancing Services Through Technology
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Addiction Technology Transfer Centers (ATTC)

• The Addiction Technology Transfer Centers are
  designed to enhance the quality of addiction
  treatment and recovery services within the region
  by providing policymakers, providers, consumers
  and other stakeholders with state-of-the art
  information through technology translation and
  transfer activities.
• ATTC is national network, comprised of 14
  regional
• centers, that serves all 50 states and the
• U.S. Territories.

This special issues Newsletter on Issues Facing
Returning Veterans is an example of recent work
with national distribution.
46
Recovery and the Military Treating Veterans
and Their Families

• One-hour webcast available on-line at
  www.recoverymonth.gov
• Also shown in more than 15-million CATV
  households.
• June 2008 CSAT Webcast on
  PTSD and Returning Veterans

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Where do we go from here?
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Shifting our Paradigm to a Recovery-Oriented
Systems of Care for Returning Veterans
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ROSC support person-centered and self-directed
approaches to care that build on the personal
responsibility, strengths, and resilience of
individuals, families and communities to achieve
health, wellness, and recovery from alcohol and
drug problems.
Recovery
Veteran Family Community
Wellness
Health
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ROSC offer a comprehensive menu of services and
supports that can be combined and readily
adjusted to meet the individuals needs and
chosen pathways to recovery.
Recovery
Services Supports
Family/Child Care
Alcohol/Drug Services
Vocational
Education
Veteran Family Community
Housing/ Transportation
PTSD Mental Health
Physical Health Care
Spiritual
HIV Services
Financial
VSO Peer Support
Wellness
Health
Legal
Case Mgt
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ROSC encompass and coordinates the operations of
multiple systems
Recovery
Systems of Care
Addiction Services System
Child Welfare and Family Services
Services Supports
Mental Health System
Social Services
Family/Child Care
Alcohol/Drug Treatment
Vocational
Housing System
Veteran Family Community
Primary Care System
Educational
PTSD Mental Health
Housing/ Transportation
Health Care
Faith Community
Vocational Services
HIV Services
Spiritual
Indian Health Services
Financial
VSO Peer Support
Legal
Case Mgt
Health Insurance
Criminal Justice System
Wellness
Health
DoD Veterans Affairs
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providing responsive, outcomes-driven approaches
to care.
Recovery
Abstinence
Evidence-Based Practice
Systems of Care
Addiction Services System
Child Welfare and Family Services
Employment
Menu of Services
Social Services
Cost Effectiveness
Family/Child Care
Alcohol/Drug Treatment
Mental Health System
Vocational
Veteran Family Community
PTSD Mental Health
Educational
Housing Authority
Crime
Housing/ Transportation
Health Care
Primary Care System
Perception Of Care
HIV Services
Spiritual
Faith Community
Vocational Services
Financial
VSO Peer Support
Indian Health Services
Legal
Case Mgt
Homelessness
Retention
Health Insurance
Criminal Justice System
Health
Wellness
DoD Veterans Affairs
Access/Capacity
Social Connectedness
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ROSC require an ongoing process of systems
improvement that incorporates the experiences of
those in recovery and their family members.
Recovery
Abstinence
Evidence-Based Practice
Systems of Care
Addiction Services System
Child Welfare and Family Services
Employment
Services Supports
Family/Child Care
Alcohol/Drug Treatment
Mental Health System
Social Services
Vocational
Cost Effectiveness
Veteran Family Community
Educational
PTSD Mental Health
Crime
Housing/ Transportation
Primary Care System
Housing Authority
Health Care
Spiritual
Perception Of Care
HIV Services
Vocational Services
Financial
VSO Peer Support
Indian Health Services
Legal
Case Mgt
Homelessness
Retention
Health Insurance
Criminal Justice System
Health
Wellness
DoD Veterans Affairs
Access/Capacity
Social Connectedness
Ongoing Systems Improvement
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Recovery Oriented Systems of Care

• Client Focused
• Cost Effective
• Efficient
• Competency Based
• Outcomes oriented

• Collaboration
• Partnership
• Non-Duplication of Services
• Community Based

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SAMHSA Workgroup on Returning Veterans and Their
Families

• Background
• Created in July 2006 as a result of
  recommendations made at SAMSHA co-sponsored
  National Behavioral Health Conference on
  Returning Veterans and Their Families.
• Workgroup partners SAMHSA, Department of Defense
  (DOD) and the Department of Veterans Affairs (VA).

56
SAMHSA Workgroup on Returning Veterans and Their
Families

• Workgroup Overarching Goal
• To improve access to mental health, substance
  abuse, and co-occurring disorders prevention,
  treatment, and recovery services for returning
  veterans from Iraq and Afghanistan and their
  families.

57
SAMHSA 2008 Returning Veterans Conference

• Sponsored by Workgroup
• Policy Academy Format
• Conducted at multiple locations to provide
  regional focus
• Attendees/participants key stakeholders from the
  mental health and substance abuse prevention
  fields, as well as state and local communities.

58
SAMHSA 2008 Returning Veterans Conference

• Conference Goals
• Increase cultural competence (system and
  clinical) in the delivery of services to veterans
  and their family members among the civilian
  community mental health and substance abuse
  provider community.
• Facilitate strategic partnerships, outreach, and
  collaboration across key civilian, DOD and VA
  psychological health related systems at the
  State, Tribal, community and local level.

59
WWII, Korea, Vietnam, Grenada, Panama, Persian
Gulf, Afghanistan, Iraq
With the active cooperation of all of society,
the road home for our veterans can be improved.
And, the journey home can be made easier.
Home
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SAMHSA Information

• www.samhsa.gov/vets
• Links to available resources for veterans
  families
• Publications or information on funding
  opportunities
• Natl Clearinghouse for Alcohol Drug
  Information (NCADI) 800-729-6686 TDD
  800-487-4889
• Natl Mental Health Information Center
• 800-789-2647 TDD 866-889-2647
• Help
• 800-662-HELP Substance Abuse Referrals (average
  of tx calls per mo.- 24,000)
• 800-273-HELP Suicide Hotline

61
TBI and Veterans the HRSA response

• The Health Resources and Services Administration
  and its Strategies to Address Traumatic Brain
  Injury among Veterans
• Jean L. Hochron, M.P.H.
• April 2, 2008

62
What well discuss

• HRSA and its resources for provision of primary
  care through Health Centers
• TBI among persons who are homeless
• HHS-VA collaboration to increase access to care
  for veterans

63
Health Resources and Services Administration
(HRSA)
64
Health Centers

• HRSA provides grant funds to over 1100 Health
  Center programs in urban and rural communities
• These programs, also known as Federally Qualified
  Health Centers, provide services in over 4000
  locations
• Locate sites at www. ask.hrsa.gov/pc/
• Some programs serve the entire community others
  target migrant farmworkers, homeless people,
  and/or people living in public housing

65

• HCtrs serve everyone in their targeted community,
  regardless of the ability to pay for care
• They provide comprehensive primary care and
  preventive services
• Many also offer behavioral health and oral health
  services
• All are required to provide enabling services,
  including outreach, translation, transportation,
  and case management
• Patients are charged on a sliding fee schedule

66

• Health Centers served over 15 million people in
  CY 2006
• Insurance status
• 40 uninsured
• 35 Medicaid
• 15 private insurance
• 7 Medicare
• 2 other public insurance
• Age/gender
• 41 male/59 female
• 63 adults 56 20-65 7 65

67

• We do not currently know how many of these
  individuals are veterans
• HRSA will begin collecting data on veterans
  status beginning with encounters occurring
  on/after January 2008

68
TBI and homelessness

• TBI is prevalent among homeless people due to
• abuse as children (note foster care is the
  highest predictor of future homelessness)
• adult victims of domestic violence
• trauma experienced on the street or in prison
• military service

69

• Many veterans of past conflicts have spiraled
  into poverty and homelessness when they do not
  get needed treatment for cognitive problems
• Estimated one out of three (13) homeless male
  adults are veterans
• Veterans account for 23 of all homeless people
  in U.S.

70

• Once on the street, high risk of severe head
  injury because
• higher probably of assault
• high risk-taking behavior
• behavioral issues leading to physical conflict
• Health Care for the Homeless (HCH) program
  grantees served 700,000 people in 2006
• 57 or 400,000 males 86.5 or 346,000 males
  age 20
• If 13 adult males are vets, then HCH served
  113,000 vets

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• Much focus on TBI within the HCH clinical
  community
• HCH Clinicians Network publication Healing
  Hands
• February 2008 issue on TBI
• www.nhchc.org/Network/HealingHands/2008/Feb2008He
  alingHands.pdf
• March 2008 case report on TBI
• www.nhchc.org/Publications/TBICaseRpt031008.pdf

72
HHS-VA collaboration

• Interagency Task Force on Returning Global War on
  Terror (GWOT) Heroes developed by VA in early
  2007
• Recommendation 0-9 Provide Outreach and
  Education to Community Health Centers
• HHS and VA working collaboratively since April
  2007 to develop initiatives to enhance
  coordination of services
• for returning GWOT service members
• other veterans
• those in rural areas with limited access to VA
  services

73
Key Components of HHS-VA collaborative activities

• Partnership to train community-based providers
• Seamless referral of vets from Health Centers to
  VA facilities
• VA contracting with community-based providers

74
Partnership to train community-based providers

• Involves the Employee Education System (EES) of
  the VA and HRSAs Bureau of Health Professions
• Will afford opportunity to share VHA training
  resources with local providers and health
  professional training institutions through HRSAs
  Area Health Education Centers (AHECs)

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Seamless referral of vets from Health Centers to
VA facilities

• Familiarize Health Centers with VA eligibility
  rules and enrollment process
• Provide HCtrs with assistance in making contact
  with local VA Medical Center and ultimately
  developing collaborative relationships

76

• Through linkage of Agency websites, hope to
  assist veterans and VA in identifying location of
  community-based services available to vets and
  their families
• medical services through HCtrs
• community-based mental health and substance abuse
  services
• services available to Native American veterans
  through Indian Health Service and tribes

77
VA contracting with community-based providers

• Many VA facilities extend services beyond the VA
  medical center through Community Based Outpatient
  Clinics (CBOCs)
• CBOC model provides VA with option of using VA
  staff or contracting with outside health care
  providers
• HCtrs are to be notified of CBOC contracting
  opportunities and directed to FedBizOpps (Federal
  Business Opportunities) for details www.fbo.gov

78
Also, fyiTools for preparing successful SSI/SSDI
applications

• Expediting Access to SSA Disability Benefits
  Promising Practices for People who are Homeless
• www.prainc.com/SOAR/about/promisingpractices.pdf
• Stepping Stones to Recovery A Case Manager's
  Manual for Assisting Adults Who Are Homeless with
  SSI/SSDI applications www.prainc.com/SOAR/tools/m
  anual.asp
• Documenting Disabilities Simple Strategies for
  Medical Providers
• www.nhchc.org/DocumentingDisability2007.pdf

79
Jean L. Hochron, M.P.H. Senior Policy
Advisor Office of Planning and Evaluation Health
Resources and Services Administration Phone
[phone] Email jhochron_at_hrsa.gov