Integrated Post Deployment Care

Transcription

1 Session # October, 2012 Integrated Post Deployment Care Stephen C Hunt MD MPH National Director VA Post-Deployment Integrated Care Initiative OMED 2012 American Osteopathic Association Annual Conference October 7 11, 2012 San Diego

2 What are the healthcare needs of returning combat Veterans?

3 Health Concerns of Combat Veterans Some health concerns are consistent after every war while others are unique to each conflict: Most common conditions for all conflicts: Musculo-skeletal injuries with pain Diagnosable mental health conditions Unexplained symptoms Dental Hearing Unique to conflict WW I poison gas; trench warfare with artillery blast exposure WW II Cold injury (European);PUD and GI complaints Korea: Cold injury Vietnam: Agent Orange PGW I: Unexplained Medical Symptoms OEF/OIF: TBI/Polytrauma 3

4 OEF/OIF/OND Veterans Approximately 2.4 million have deployed since ,515,707 OEF/OIF/OND Veterans have separated from service and are eligible for care 55% (834,463) of these have obtained VA health care since FY 2002(cumulative total) 56% are former active duty and 54% are reserve and national guard 88% male, 12% female 1st Quarter FY 2002 through 3rd Quarter FY 2012 Office of Public Health and Environmental Hazards Sept

5 What are the health concerns of OEF/OIF/OND veterans seen in the VA? Musculoskeletal Mental disorders Ill defined conditions Nervous system (hearing) GI (dental) Endocrine/Nutrition Injury/Poisoning Respiratory 57.1% 53.3% 52.4% 45.3% 36.1% 32.9% 26.5% 25.7% VHA Office of Public Health and Environmental Hazards: Released Sept

6 Physical risks of combat Body armor, heavy loads, lifting, strenuous activities, combat injuries, MVAs, IEDs, physical training

8 A total of 444,505 unique patients have received one or more mental health diagnoses Disease Category (ICD 9: ) # of Veterans PTSD 239,094 Depressive Disorders 184,404 Neurotic Disorders 161,510 Affective Psychosis 111,199 Alcohol Dependence Nondependent Abuse of Drugs 37,547 Specific Non-Psychotic Mental Disorder due to Organic Brain Damage 28,828 Special Symptoms, Not Elsewhere Classified 32,268 Sexual Deviations and Disorders 26,788 Drug Dependence This data excludes PTSD data from the VA Vet centers, the 90,303 with tobacco use disorder, the 22,156 with alcohol use disorder and the 17,188 with both TOB and ETOH but no other MH disorder. Cumulative from 1st Quarter FY 2002 through 1st Quarter FY

9 Mental Health Diagnoses, not Diagnosis 28% Two Diagnoses 35% > Three Diagnoses 37% Single Diagnosis

10 Co-morbid Concerns in Combat Veterans Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009 JRR&D Sample = 340 OEF/OIF outpatients at Boston VA TBI/Pain 12.6% 10.3% 5.3% 6.8% Overall prevalence: Pain 81.5% TBI 68.2% PTSD 66.8% CLARK P3 Multi symptom Disorder 42.1% PTSD 2. % 16.5%

12 Rate the degree to which you believe Persian Gulf Illness is: P e r c e n t Richardson RD, Engel CC, McFall, M, McKnight K, Hunt SC. Clinician Attributions for Symptoms and Treatment of Gulf War-Related Health Concerns. Archives of Internal Medicine 2001; 161:

13 Rate the degree to which you believe Persian Gulf Illness, in general, is most effectively treated by: P 30 e r25 c 20 e n15 t Internal Medicine (n = 77) Mental Health (n = 176) Mostly Biological Interventions Mostly Psychological Interventions Richardson RD, Engel CC, McFall, M, McKnight K, Hunt SC. Clinician Attributions for Symptoms and Treatment of Gulf War-Related Health Concerns. Archives of Internal Medicine 2001; 161:

15 Our 26 y/o Combat Veteran is more likely to have: physical injuries be taking opioid pain medications diagnosable mental health conditions as well as sub-syndromal mental health issues unexplained symptoms with general health decline hearing problems dental problems psychosocial distress: marital, occupational, financial, social risk of injury/death from incidental trauma At least a 2-3 fold increased risk of suicide And he is much less likely to show up for his appointments!

16 Our 26 y/o Combat Veteran is more likely to need: Deployment focused care Pain management intervention Evidence based MH care MH support for MH issues not meeting criteria for specific diagnosis Behavioral health support: health recovery Expedited dental care (within 6 months of discharge) ETOH/SUDs intervention Support for: marital, vocational rehabilitation, securing employment, temporary financial, temporary housing Expedited compensation claim Ongoing monitoring for suicide risk

17 Post-Deployment Health Care Needs Noncombat injury Combat injury Marital/family financial TBI difficulties Non-combat illness Post-combat Environmental Spiritual / symptoms exposure existential illness struggles Hearing loss tinnitus Mental health C&P needs

18 Post-Deployment Health Care Needs Noncombat injury Combat injury Marital/family financial TBI difficulties Non-combat illness Post-combat Environmental Spiritual / symptoms exposure existential illness struggles Hearing loss tinnitus Mental health C&P needs

19 What are the stressors of war? Physical injury temperature diet toxic agents multiple immunizations noise sleep deprivation austere conditions infectious agents blast wave/head injury Psychological anticipation of combat combat trauma non-combat trauma separation from family/home deprivation Psychosocial marital/parenting issues social functioning occupational/financial concerns risk of re-deployment spiritual / existential

20 Integrated Post-Combat Care Physical Psychological Veteran Psychosocial

21 Initial response to Iraq/Afghanistan conflicts Polytrauma system of care OEF/OIF program developed and program managers mandated at each facility Transition Patient Advocates funded Mental Health teams formed Enhanced Pain Programs 11/9/

22 Integrated Post-Combat Care PDICI: Post Deployment Integrated Care Initiative 2008 Medical Provider MH Provider Veteran Social Worker

23 Integrated Post-Combat Care Nationwide Community of Care for Returning Combat Veterans and Their Families Culturally sensitive care Military culture: acknowledge service Combat culture: acknowledge sacrifice Community Providers Collaborate with local VA facilities, Vet Centers, community resources Integration of care: Medical services Mental health services: screen for co-morbid conditions, address chronic pain, TBI, sleep Social services: family, job, educational, financial

24 What do all of these patients have in common? 41 yo male accountant with obesity and DM 27 yo female office worker with PTSD, 24th week IUP 36 yo male nurse with labile HTN 60 yo male lawyer with HIV/AIDS complications 42 yo female shopkeeper with MS 68 yo male social worker CHF, hep C, depression 82 y/o male with dementia, recently widowed 57 y/o female bus driver with breast cancer

25 They are all Veterans But you won t know unless you ask! SOMALIA IRAQ AFGHANISTA N VIETNAM KOSOVO WWII GULF WAR I KOREA

26 Clinical Pearls for Care of Combat Veterans Take a military service history (Ask, Listen, Learn) Tell me about your military experience and how it affected you? What was your job and where did you serve? Did you see combat, enemy fire, or casualties? Were you sick, wounded, injured or hospitalized? Were you exposed to blasts? Express gratitude for service and sacrifice Understand barriers to care: stigma/ family/work/school o Psychological symptoms as barriers PTSD: avoidance Depression: low motivation/apathy Substance use disorders: denial, poor adherence Mild TBI: poor concentration and memory

27 Clinical Pearls for Care of Combat Veterans Mild to moderate readjustment difficulties Monitor for progression Assess for sleep disturbance, Screen for substance abuse Ask about relationship/work/school issues o Close follow-up, involve family o Focus on function Ask how they are doing Ask how are their relationships, their job, school o VA Post Deployment Program Managers help with community and VA coordination of services

28 Clinical Pearls for Care of Combat Veterans Musculoskeletal pain Co-morbid mental health conditions lower pain thresholds Effective treatment strategies must address both Orient toward self efficacy, self management, non-pharmacological strategies Reserve opiates for select/refractory cases given high risk for substance misuse/abuse. Utilize interdisciplinary approach Sleep Sleep hygiene: substance use, exercise, BH prazosin for nightmares(1-2mg 15mg qhs); consider stepped approach Benadryl trazodone ambien PTSD psycho education, engagement De-stigmatize mental health care, treat co-morbid conditions referral for evidence based therapy. Start SSRI, avoid benzodiazepines

29 Web-Based Applications MilitaryKidsConnect.org AfterDeployment.org SuicideOutreach.org

30 Mobile Applications

31 WEB Resources Public VA site with comprehensive information and links for our Returning Service Members VA Mental Health services: PTSD care with information for Veterans and for Providers: Wellness resources for the military and veteran community: VA/DoD Clinical Practice Guidelines : PTSD, TBI, MUS The National Resources Directory (NRD) provides access to services and resources at the national, state and local levels that support recovery, rehabilitation and reintegration: VA has gone mobile to read and share VA information, news stories find facilities on the go: Information on environmental and occupational hazards during military: JGIM: Post Deployment Care for Returning CombatVeterans CDC: Preventing Chronic Disease. A Population Approach to Mitigating the LongTerm Health Effects of Combat Deployments.

32 Session # October, 2012 Home from War Working Together to Support our Returning Combat Veterans and Their Families OMED 2012 American Osteopathic Association Annual Conference October 7 11, 2012 San Diego