3 Questions of Personal Liability

1
(No Transcript)
2
VA Puget Sound Health Care System
Innovations in Health Care of OIF/OEF
VeteransOutreachService Delivery
ModelTreatment ApproachesResearch
3
Joint VA/DoD Task Force RecommendationsAdopt a
Public Health Approach

• Proactive case-finding through outreach
• Education of unit commanders, family, employers
• Early detection and intervention through
  screening
• Inter-agency partnerships and sharing agreements
• Seamless transition from DoD to VA and Vet Center
• Reduce stigma by emphasizing normalizing
  readjustment problems
• Primary care-based service delivery of mental
  health
• Expectations for wellness, recovery, resilience,
  rehabilitation
• Facilitate vocational rehabilitation and job
  re-entry

4
Outreach Inter-agency Collaboration
5
I. Northwest Network Deployment Health
SummitRegional Conference Nov. 8-9, 2004

• Familiarization of partners involved in health
  care of soldiers/veterans
• Education about nomenclature, function, and roles
  of each agency
• Inventory, map, and coordinate assets adjacent to
  concentrations of returning veterans
• Identify unmet mental health needs of veterans
  and deficiencies in services
• Develop an action plan for outreach and tailored
  interventions at facility, state, and regional
  levels (identifying resources needed and
  interagency sharing agreements to develop)

6
I. Northwest Network Deployment Health Summit
Participating Stakeholders

• Leaders from all branches of DoD (regular active
  duty and reserve component)
• Constituents (returning combat soldiers)
• Regional VAMCs
• Vet Centers
• State Department of Veterans Affairs
• TriWest

7
I. Northwest Network Deployment Health Summit
Follow-Up Monitoring of Progress

• Publication of Summit proceedings (contact info,
  action plan, resource lists, etc.)
• Jointly Organized and Attended Regional Training
  Conferences for VA, DoD, and community
• Monthly planning meetings of inter-agency
  partners
• VA/DoD Collaborative Research (clinical trials)
• Sharing Agreements for Clinical Care with DoD
• VAPSHCS inpatient medicine service at MAMC
• MAMC inpatient psychiatry service at VAPSHCS

8
II. Interagency Memo of AgreementPurpose

• Formal interagency agreement (MOA) that defines
  the mutually agreed upon requirements,
  expectations, and obligations of federal and WA
  state agencies to deliver social and health
  services to veterans.
• Stipulates a coordinated plan for outreach,
  education, and clinical service delivery to
  members (including family) of the Washington
  State National Guard and reserve units.
• Involved cooperative interagency planning, lead
  by WDVA and WA National Guard
• Commitment to provide customer service, not just
  briefings, 3-6 months following deployment.

9
II. Memo of Agreement (Contd)Participating
Partners

• Washington State Military Department
• Washington State Department of Veterans Affairs
• Department of Veterans Affairs (VHA and VBA)
• Washington State Employment Security Department
• U.S. Department of Labor
• Washington Association of Business
• Governors Veterans Affairs Advisory Committee

10
II. Memo of AgreementResponsibilities

• Directive to National Guard and reserve unit
  commanders by the Adjutant General
• WDVA provides a point of contact to the WA
  National Guard Family Support Network (respond to
  inquiries regarding benefits and assist Family
  Support Coordinator with emergencies).
• WDVA provides a coordinator for FAD events.
• WDVA sends letters to all recently discharged
  veterans in WA, signed by the Governor, Adjutant
  General, and Director DVA, describing services.
• VA and other agencies send volunteers to FADs and
  provide follow-up social services

11
II. Memo of AgreementService Delivery Outcomes
from Outreach

• 31 total FAD/PDHRA events for 42 units (2005 thru
  May 2007)
• Average 18 volunteers per event
• Total participants at FAD events 2,900
• Outcomes from the FAD events for participants
• Mental health referrals made to 41
• On-site enrollment in VHA health care for 50
• On-site filing of claims for compensation for 18
  
• On-site employment assistance provided to 24
• TriCare briefings to 91

12
Service Delivery Model
13
VA PSHCS Mental Health Services for OIF/OEF
Veterans Organizational Diagram
14
Collaborative and Coordinated Care
Center For Polytrauma Care
Deployment Health Clinic
PTSD Programs
15
Deployment Health Clinic Integrated Care for
Combat Veterans

• Integrated mental health and medical care
• Preventive/health promotion based care
• Family involvement in care
• Brief CBT interventions
• Case management
• Disability benefits
• Vocational rehabilitation consultation
• Referrals to inpatient/outpatient mental health
  services (PTSD, substance abuse, general mental
  health services) or specialty medical clinics
  within the VA Medical System

16
Deployment Health Clinic StaffingSeattle Division

• Two 0.5 FTEE Primary Care Physicians
• 0.5 FTEE ARNP
• Clinical Psychologist
• Postdoctoral Fellow
• Psychology Intern
• Mental health counselor
• 0.5 FTEE Psychiatrist
• 1.0 MSW
• Vocational Rehabilitation Specialist

17
Improved Access to CareAdditional Strategies

• Improve access to care (after hours clinics,
  telemedicine)
• Deploy prescribers to Vet Centers with TM
  follow-up
• Focus on spectrum of deployment-related
  readjustment problems mental disorders, not
  just PTSD
• Use a stepped-care approach (start with
  education skills building)
• Health promotion (tobacco, inactivity, obesity,
  etc.)
• Fast track emergency bed on PTSD Inpatient Unit
• Assess and accommodate patient preferences for
  treatment

18
Patient Preferences Setting of Care
Clinic Setting Percent
Deployment Clinic 74
Specialty Mental Health Clinic 11
Primary Care Setting 6
19
Patient Preferences Types of Service
Intervention Prefer (Do Not Prefer)
Employment, housing, finances 32 (46)
Counseling for symptoms 38 (33)
Medications 42(36)
20
Treatment PreferencesModes of Counseling Delivery
Modes of Delivery Prefer (Do Not Prefer)
Individual sessions by Telephone 12 (72)
Face-to-face individual sessions 44 (22)
Group sessions 10 (76)
Couples or family sessions 12 (63)
More likely to attend sessions if early morning or evening availability (yes/no) 61
Would like to use e-mail to stay in touch with counselor (yes/no) 63
21
Patient Preferences Types of Counseling
Intervention Prefer (Do Not Prefer)
Talking about combat experiences 33 (43)
Talking about how I think and feel now without going into combat experiences 43 (27)
Practical advice to solve current problems 50 (19)
Engaging in activities that will improve my feelings 46 (18)
Improving how I related to others and communicate 46 (20)
Learn skills for calming down and reducing stress 55 (16)
Learning how to take better care of my physical health (e.g., losing weight, stopping smoking, etc.) 49 (33)
22
Special Clinical Emphasis AreasQuality
Improvement Needs Assessment (N 420)
Measure PTSD () No PTSD () OR (95 CI)
Problematic ETOH use 21.4 6.5 3.9 (1.7-9.0)
Problematic drug use 3.1 1.9 ns
Current smoking 32.0 22.4 ns
Exercise deficient 82.1 49.5 4.69 (2.8-8.0)
23
Special Clinical Emphasis AreasQuality
Improvement Needs Assessment (N 420)
Measure PTSD () No PTSD () OR (95 CI)
Suicide risk 21.2 0.9 28.2 (3.8 208.8)
Attempted suicide last 4 months 4.1 0.9 ns
24
Special Clinical Emphasis AreasQuality
Improvement Needs Assessment (N 420)
Measure PTSD () No PTSD () OR (95 CI)
severe pain 24.5 8.3 3.6 (1.8-7.3)
poor physical health 23.0 3.7 7.7 (2.7-22.1)
poor sleep 80.3 33.2 14.9 (8.6-25.6)
25
Special Clinical Emphasis AreasQuality
Improvement Needs Assessment (N 420)
Measure PTSD () No PTSD () OR (95 CI)
Verbally abusive last 4 months 62.8 18.6 7.4 (4.1-13.4)
Destroyed Property last 4 months 25.4 6.2 5.2 (2.1-12.6)
Threatened someone with violence last 4 months 33.0 7.2 6.3 (2.7-14.5)
Had a physical fight last 4 months 15.5 4.1 4.3 (1.5-12.5)
Thoughts of hurting someone last 4 months 62.8 14.4 10.0 (5.3-18.9)
26
Research
27
I. Prazosin for PTSD
28
Prazosin for PTSD-Related Nightmares

• Blockade of CNS alpha-1 adrenergic receptors with
  a lipid soluble antagonist will reduce nighttime
  PTSD symptoms.
• Prazosin is the only lipid soluble alpha-1 AR
  antagonist thus, the only one that easily enters
  the brain.

29
First Efficacy DemonstrationPrazosin vs.
Placebo Crossover Study

• 10 Vietnam combat veterans (age 53 3 years)
  randomized to
• placebo followed by prazosin (n 5)
• prazosin followed by placebo (n 5)
• Titration schedule
• 1 mg q.h.s. x 3 nights, 2 mg x 4 nights, 4 mg x 7
  nights, 6 mg x 7 nights, 10 mg for 6 weeks

30
Results Primary Outcome Measures
Prazosin Placebo p value
CAPS Distressing Dreams
baseline endpoint 6.9 0.9 3.6 2.6 7.1 0.9 6.7 1.6 lt 0.001
CAPS Difficulty Sleeping
baseline endpoint 7.4 1.3 4.0 2.3 7.3 0.9 7.1 1.9 lt 0.01
Total CAPS
baseline endpoint 79.1 17.0 57.3 11.4 83.6 17.6 86.5 30.0 lt 0.01
CGIC
endpoint 2.0 0.5 4.5 1.8 lt 0.01
Raskind, MA et al., Am J Psychiatry 160371-373,
2003.
31
Clinical Global Impression of Change for Overall
PTSD Symptoms
Prazosin
markedly improved moderately improved minimally
improved no change minimally worse moderately
worse markedly worse
1 2 3 4 5 6 7
Placebo
32
Second Efficacy DemonstrationPrazosin vs.
Placebo Parallel Group Study
Outcome Measure Prazosin (n 17) Placebo (n 17) statistic (change scores) Effect Size (Cohen's d)
CAPS Distressing Dreams Baseline Endpoint 6.5 ? 1.0 2.9 ? 2.7 6.1 ? 1.0 5.2 ? 2.2 t 2.48 0.9
PSQI Baseline Endpoint 13.5 ? 4.2 9.7 ? 3.9 13.4 ? 2.7 12.6 ? 4.1 t 2.82 0.7
CGIC (endpoint) 2.3 ? 1.0 3.7 ? 1.2 t 3.56 1.3
CGIC proportion moderately or markedly improved 12/17 2/17 Fishers Exact plt0.001 N/A
plt0.01, plt0.001
Raskind et al. Biol. Psychiatry 2007 61 928-934
33
II. Behavioral Activation
34
Alternative PsychotherapiesContraindications for
Evidence-Based PTSD Approaches

• Most OIF/OEF VA patients with mental disorders
  dont have PTSD.
• Difficulty engaging OIF/OEF patients in
  traditional psychotherapy (e.g., high no show
  rates).
• Prevalence of TBI and other comorbidities may
  contraindicate emotionally evocative therapies.
• Higher dropout rates with exposure therapy.
• Reluctance of therapists/patients to revivify
  trauma memories.
• Comparative trials show evidence-based therapies
  work about equally well.

35
Behavioral Activation

• Present centered, outside in behavioral
  approach that targets
• avoidance and restricted range of behavior ?
  diminished rewards
• ruminative thinking
• disruption of normal routines
• Identify and engage in reinforcing activities
  consistent with long-term goals and values.
• In vivo exposure through graded task assignments
  that facilitate mastery through re-engagement in
  formerly pleasurable activities.
• Results from homework monitoring of activities
  and mood reviewed in therapy to establish linkage
  between actions and emotional states.
• Easy to implement and highly acceptable to
  patients.

36
Rates of Response and Remission (BDI) High
Severity Subgroup
76
48
49
37
BA for Treatment of PTSD

• Open trial of 11 PTSD patients1
• Mean symptom reduction on CAPS 12 points
• Five of 11 veterans showed statistically reliable
  change
• 4 of 11 veterans lost diagnosis of PTSD
• Jackupak, Robeerts, Maerrtell, Mulick, Michael,
  Reed, Balsam, Yoshimoto, McFall. A pilot study of
  behavioral activation for veterans with PTSD. J
  Trauma Stress 2006 19 387-391.

38
III. Integrated CareHealth Promotion in PTSD
39
Rationale for Integrating Health Promotion Into
Post-Deployment Mental Health Care

• Providers have advanced training in treating
  behavioral and substance use disorders applicable
  to nicotine dependence
• Positioned to tailor cessation treatment to
  address the dynamic interaction of tobacco use
  with psychiatric symptoms
• The frequent, continuous nature of mental health
  care naturally promotes ongoing monitoring of
  smoking status and reapplication of treatment to
  encourage recycling
• Mental health clinics expand access to smoking
  cessation treatment for otherwise underserved
  veterans and overcome logistical barriers to care

40
Integrated Care versus the Usual Standard of VA
Care for Smoking Cessation in PTSD A Randomized
Clinical Trial McFall, M., et al. Improving
Smoking Quit Rates for Patients with PTSD. Am J.
Psychiatry 1621311-1319
41
Objective

• To compare the effectiveness of brief
  Integrated Care (IC) versus VAs Usual Standard
  of Care (USC) for nicotine dependence in veterans
  undergoing mental health treatment for PTSD.

42
Integrated Care Overview of Clinical
Intervention

• Behavioral Counselinga
• Pharmacotherapy
• Self-help readings
• Relapse prevention/recovery and maintenance
• ____________
• a Six weekly sessions (20 minutes each) plus
  discretionary follow-up visits.

43
Clinical Outcomes7-Day Point Prevalence for
Non-Smoking Status (n66)
non-smoker
Assessment Period
GEE Analysis Results Odds Ratio 5.23, p lt
.0014
44
Practice-Based IC for Smoking Cessation An
Open Clinical Trial McFall, M. et al.
Integrating Tobacco Cessation Treatment into
Mental Health Care for PTSD. American Journal of
Addictions 2006 15 336-344.
45
7-Day Point Prevalence Abstinence and Percent
Reduction for Continued Smokers (n 107)
Percent
Assessment Period
46
Conclusions from Preliminary Work

• It is feasible to incorporate guideline-based
  smoking cessation treatment into routine delivery
  of mental health care for PTSD
• Integrating treatment of nicotine dependence is
  more effective than the usual standard of VA care
  within the VAPSHCS, for PTSD patients
• IC was a better vehicle than USC for for
  delivering cessation treatments of sufficient
  intensity, which may explain the superior results
  of IC

47
Partners
Function
Mental Health

• Complicated/Severe cases
• Patients who accept a PTSD Diagnosis
• Specialized interventions

• PTSD Inpatient and Outpatient programs
• Addictions programs
• Voc Rehab Services

• Uncomplicated mental disorders
• Screening, education, brief supportive Rx
• Triage to Mental Health

• Deployment Health Clinic
• SCI and RMS
• Poly Trauma Program

Primary Care Specialty Medicine

• Seamless Transition to MTF
• Vet Center VA Outreach
• Drill Weekends

• Family Activity Day
• PDHRA screening
• Educational resources

Community Outreach Case Finding

• VA State DVA
• Vet Centers
• DoD (Military Director)
• Dept. of Labor

Interagency Collaboration

• Sharing agreements
• Cross referral
• Educational meetings

• Network Director
• Facility Director
• Service Lines

• Resources
• Organization
• Mission priority

Administrative Infrastructure
48
Extras
49
Prevalence of PTSDStringently Defined
Population Prevalence
Viet Nam Veterans 9 15 (20 30 lifetime)
Persian Gulf War Veterans 2 10
Afghanistan Active Duty 6.2
Iraq Active Duty 12.6
US General Population 5 males (lifetime) 10.4 females (lifetime)
50
Distressing Mental Health Symptoms Liberal
Screening Criteria (Iraq Vets)
Disorder(s) Screening at Demobilization Delayed Screening
PTSD 9.8 18.9 - 34.6
Depression 4.5 15.2 - 30
PTSD, depression, or GAD 19.1 28.5 - 40
51
Barriers to Mental Health CareVAPSHCS Deployment
Clinic Sample (N 235)
Barrier Agree
Difficulty scheduling an appointment 17
Difficult getting time off work 20
Concerned about financial costs of Rx 38

It might harm my career 21
Co-workers have less confidence in me 23
My employer would treat me differently 24

I would be seen as weak by others 28
I would feel weak or down on myself 13
52
Barriers to Mental Health CareVAPSHCS Deployment
Clinic Sample (N 235)
Barrier Agree
Dont want to be prescribed medications 24

Dont think MH treatment will help me 9
Visits with MH professional not confidential 10
Dont want to talk about upsetting war events 12