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Witness Testimony of Ian A. Shaffer, M.D., MHN, A Health Net Company, San Rafael, CA, Chief Medical Officer

INTRODUCTION

Mr. Chairman and distinguished members of this Committee, I would like to thank you for inviting us to share our experiences with the VetAdvisor Support Program, an innovative pilot program designed to assist Veterans Integrated Service Network (VISN) 12 Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans learn about and obtain Veterans Health Administration (VHA) mental health care services.  We appreciate the opportunity to offer our perspective on how this unique, proactive telephonic outreach program serving OEF/OIF veterans uses innovative solutions to help address physical and behavioral health issues common to those serving in combat. 

We thank the Committee for its leadership and interest in this important issue and for allowing us to educate the Committee on a proactive behavioral health outreach program we believe has the potential to assist veterans not only in VISN 12, but in VISNs across the country.  Recently, a blue ribbon panel praised the VA for its “comprehensive strategy” in suicide prevention that includes a “number of initiatives and innovations that hold great promise for preventing suicide attempts and completions.”  We believe that VetAdvisor plays a role in this strategy.

PROGRAM OVERVIEW

As the Committee is acutely aware, OEF/OIF veterans face many stressors and adverse situations – life-changing events that may impact their professional and personal lives for a long time.  After returning home from deployment in Iraq or Afghanistan, veterans may suffer from health issues such as post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, social withdrawal, drug/alcohol abuse, and suicide ideation. VISN 12 recognized the need to ensure that all OIF/OEF veterans have access to the health care services they may need via a seamless transition into VHA.  VISN 12 also recognized the fact that, in order to be most effective at identifying and preventing behavioral health issues, mental health services must be integrated into the primary care system.  To address these needs, VISN 12 established a pilot program designed to reach out to OEF/OIF veterans.

This pilot program, now called VetAdvisor, consists of two distinct programs:

 Program One - Welcome Home Program – Outreach and Screenings

  • Eligible OIF/OEF veterans are called, welcomed home and thanked for their service,
  • Veterans are made aware of healthcare services available to them,
  • Veterans are asked if they would like to complete a telephonic screening to assess for common health conditions associated with service as a combat veteran (TBI, PTSD, Suicide Risk, Depression, Alcohol, etc.),
  • Screening results are shared with the VA Medical Center (VAMC) medical and behavioral health teams; and
  • Veterans who screen positive on the assessments are offered more in depth evaluation, and guidance by the specific VAMC medical and behavioral teams.

Program Two – The Total Health Program – Care Coaching

  • Veterans are identified whose behavioral issues may have an impact on their well being,
  • Once identified, they are encouraged to enroll in the Total Health Program,
  • A Care Coach is assigned for regular contact, advocacy and support,
  • Coordination continues with veteran, Care Coach, and Primary Care Physician for an extended period,
  • Program design recognizes behavioral challenges and empowers Veterans to overcome these setbacks to successfully rejoin the civilian lifestyle utilizing existing support programs available,
  • Care Coach and Veteran collaborate to support change by setting goals and objectives in response to the veteran’s needs; and
  • A proactive solution is developed to address specific issues, but in addition a total health care program is planned.

Three Wire, a Service Disabled Veteran-Owned Small Business (SDVOSB), and MHN, were honored to be chosen by VISN 12 to administer its VetAdvisor Support Program (www.vetadvisor.org). 

The VetAdvisor pilot program provides vital outreach and screening to veterans for behavioral issues that might otherwise go unrecognized and therefore, unresolved.  Since eligible veterans may be busy focusing on re-integrating back to their jobs and families, or they may live in rural areas with no nearby VA medical facility, the program is based on a model where OEF/OIF veterans are proactively contacted.  VetAdvisors’ telephonic approach addresses these needs, providing service when and where the veteran chooses.

While VetAdvisor screens for a number of potential behavioral health conditions, the program has a strong suicide prevention component. When the program began in February 2008, Care Coaches were providing a basic screening for suicidal tendencies. In May, VISN 12 provided our Care Coaches with a more in depth ‘Global Assessment of Risk’ to complete for any veteran with an initial positive screening result.  This detailed assessment provides more in-depth feedback on the individual’s state of mind to better indicate any need for immediate intervention.

The VetAdvisor Support Program uses VA-approved screening tools to help identify those veterans who might be thinking about suicide.  With early identification, the VA can assist veterans who screen positive in obtaining needed support services.  If a veteran is identified as being in a crisis situation while completing the suicide screening, the Care Coach follows approved protocols to provide help and ensure the veteran is safe.  After resolution of the emergent situation, the Care Coach follows up directly with the specific VAMC to provide notification on a 24 hour a day basis, 365 days a year.

HOW VETADVISOR WORKS

VetAdvisor provides telephonic outreach to recently returned OEF/OIF veterans within VISN 12.  They are reached at home, or on mobile phones, and follow-up screenings can be scheduled at a time convenient to the veteran.  By design, this program attempts to reach veterans when they have an opportunity to really listen and to understand the services that are available to them.  Moreover, it is designed to help motivate veterans who realize they may benefit from help -- to seek that help.

An outbound call made by a counselor overcomes any reluctance a veteran may have to call for help. Moreover, by calling all OEF/OIF veterans, it helps to reduce the “stigma” of accessing mental health care.  The call is completely private and confidential – only ‘duty to warn’ (risk to self or others) applies and is explained to the veteran.  Further, the contact presents an opportunity for the veteran to think about the issues that are being screened, permitting them to look at their struggles in a safe, non-threatening way.

Identification of Eligible Veterans

Each VA Medical Center in VISN 12 provides contact information for OEF/OIF veterans on file in the VAMC’s catchment area.  Our customer service representatives (CSRs) then review the veteran information prior to placing the outbound call to familiarize themselves with the veteran and his or her background.  This review also allows the CSRs to identify veterans who recently were called by the VAMC to avoid duplicating efforts and to minimize the amount of calls veterans receive.

Outreach Activities

Once the veteran’s data is received, it is entered into a VetAdvisor database that resides on the VA system and is protected by VA security measures.  The CSRs and Care Coaches are able to access specific veteran information.  This allows them to track attempted and completed outgoing calls, as well as to update veteran contact information.  All updated contact information is shared with the VAMC so that the veterans’ records can be updated.

The “Welcome Home” component begins with outreach calls to OEF/OIF veterans. With the first call, our customer service representatives extend a warm welcome home to the veterans and thanks them for their service to our country. As the conversation continues, the CSR will inform the veteran of VA health care programs for health conditions that are often a result of serving in combat.

Proactive outreach action is a major plus of this program. The veteran is contacted where they live and offered a friendly ‘thank you’ and ‘did you know about the medical services available to you free of charge from the VA?’  CSRs approach the initial call in a friendly, matter of fact manner.  A typical call begins:   “Hi, I’m calling on behalf of the Department of Veterans Affairs and just wanted to say ‘Welcome Home’ and thanks for your service.  I’ve been talking to a number of veterans who have told me that they are not sleeping very well, or they are feeling a little withdrawn or they might be drinking a little more than usual.”  The CSR then explains the screening process and provides an overview of services available at the VA.

If the veteran agrees to participate in the VetAdvisor program, our CSRs will immediately “warm” transfer the veteran to a licensed clinician (Care Coach) for the completion of the screening process.  Alternatively, if the veteran prefers a more convenient time, the CSR will schedule the veteran for a future telephonic appointment. The database allows the CSR to schedule the appointment as well as make any appropriate notes. It also allows the Care Coaches to retrieve the appointment information and to call the veteran back at the designated time for the screening process.

The CSRs’ goal is to make contact and to schedule a screening by a Care Coach. They do this utilizing a warm, non-threatening approach in welcoming the veteran home. The screens they use are designed to elicit feedback from the veteran in a manner that encourages dialogue. The Care Coaches’ goal is to successfully contact the veteran, complete the screenings and provide those outcomes to the VA. They employ a more clinically disciplined screening process since the initial contact with the CSR has prepared and put the veteran at ease for this component of the interview/discussion.

Should the veteran screen positive for medical conditions, PTSD, depression, TBI, substance abuse, or suicidal thoughts/tendencies, the Care Coach sends a general e-mail screening notification (containing no personal health information) to the appropriate individuals at the specific VAMC for follow-up.  All positive screenings are placed in a secured shared folder where VetAdvisor and VAMC personnel can retrieve the comprehensive screening results. 

The screening results are then discussed with the veteran.  The purpose of this feedback is so veterans will have a better understanding of the evaluation and will be more likely to accept help following the interview.  Our experience suggests that in a private call where the veteran is not face to face with a clinician, the veteran is likely to open up and provide more candid responses.

Transfers to the VHA

The overall goal of VetAdvisor is to help the Veteran attain access to health care services at the proper point in the continuum of care. Veterans who screen positive for any of the six conditions will receive follow up from VA personnel at the appropriate clinic. Care Coach screenings are completed from scripts located within the VetAdvisor database (housed within the VA’s IT systems).  The results of a positive screen are automatically generated to a ‘positive screening folder’ and a generic email is generated to individuals identified by the VA as points of contact at the impacted VAMC.   These individuals can access this screening report and provide appropriate follow-up from VA clinics within that VAMC.

Early Intervention – Identifies Those With The Potential To Be At Risk

VetAdvisor operates independently of Post Deployment Health Risk Assessments (PDHRA) (required by DOD) that are usually conducted 60 – 90 days following deployment.  Thus VetAdvisor may reach the veteran prior to the PDHRA or at a later time when the veteran is ready to talk, particularly since individuals may be more apt to provide information regarding their transition in a private (i.e. telephonic) setting.  This follow up also could reach veterans who separated from the service and were not provided the PDHRA.

Where Implemented To Date

The pilot program was initiated to contact 5,000 OEF/OIF veterans in VISN 12.  It was first implemented within the North Chicago VAMC beginning with “Welcome Home” calls in February 2008.  It has been expanded to include Madison and Milwaukee, and we expect to include all remaining VAMCs (for a total of seven VISN 12 VAMCs) by the end of the year. 

Staff Qualifications

VetAdvisor employs customer service representatives who are skilled at reaching out to individuals and are specially trained in working with veterans, with special emphasis on veteran issues related to serving in combat.  They are able to demonstrate great tact in talking to veterans about potential physical and mental health problems they may be encountering post deployment.  Our clinicians are licensed behavioral health clinicians with the experience and training to conduct effective telephonic assessments and are trained in the special needs of veterans who have served in combat. 

PROGRAM SUCCESSES/RESULTS

The success of VetAdvisor stems from the proactive, personalized approach to contacting veterans and welcoming them home, setting the stage for a more thorough assessment of the veteran’s behavioral health status.  Key points of its success include:

  • The program provides a method of reaching out to patients in their homes where they are comfortable and allows for the veteran to be more willing to share some of their concerns.
  • This program demonstrates that veterans are willing to admit to serious issues in a telephone interview.
  • The screenings are identifying veterans with issues, and the screening can be a useful way of beginning a referral process for getting veterans the required treatment.
  • There has been a high interest and gratitude from veteran community for the VetAdvisor Program. Of the veterans contacted to date, many have expressed their interest and appreciation of the program.

Program Statistics

 Demographic Data:

  • 32% aged 21-25; 31% aged 26-30, and 37% over 30.
  • 89% male; 11% female
  • Over half the group never married; 33% were married
  • 49% ended active duty in 2006 or 2007.  Others ended duty between 2003 and 2005.

Overall Screening By Issue For The Entire Group:

  • 47% screened positive for substance abuse
  • 67% screened positive for medical symptoms
  • 17% screened positive for traumatic brain injury
  • 28% screened positive for PTSD
  • 11% screened positive for depression; 23% showed possible indications
  • 14% screened positive for suicide if the veteran screens positive on an initial suicide screening the VA has provided and asked that the Care Coaches complete a more in depth ‘Global Assessment of Risk’ to better identify an individual’s risk of suicidality.
  • 70% screened positive on at least one issue

** These statistics are for NCH and Madison VAMCs, which have been completed to date.  However the statistics also include Milwaukee data, which may skew the results slightly as we are in the early stages of calls and have not collected comprehensive data.

CONCLUSION

VetAdvisor is identifying veterans who have not yet, and possibly never would, reached out to VA, assessing their issues, helping them understand the power and benefit of the VHA system and encouraging them to participate. Because the program is tailored to recognize the common strengths of the VISN, as well as specialized services of each VAMC, veterans receive the kind of guidance that encourages them to use the system rather than lead to frustration.

VetAdvisor functions well as a standalone pilot and is well suited to complement a variety of VA programs and initiatives designed to contact combat veterans who have not registered or accessed services by the VA.  VetAdvisor clearly provides the next level of care and is therefore well suited to serve as a follow on program.  VetAdvisor represents an excellent example of using contract services to reach a broad audience of veterans and provide tailored support and referral back to the most appropriate resources within the VHA.

Program Advantages:

  • Outreach provided to a population, who for many reasons, will not seek help
  • Willingness of the veteran to answer questions openly in the privacy of their home
  • Ability of the veteran to listen as screening results are reviewed and recommendations made
  • Prompt referral to the VA for an initial evaluation for treatment fosters increased program participation, which can lead to better outcomes
  • Continuing access to a care coach means the veteran has someone to reach out to when unsure/needed, rather than to just drop out of treatment
  • The Program offers support through a robust call center, providing 24x7 coverage allowing for access most convenient for the veteran and a source of help should the veteran need to talk with a clinician at anytime

On behalf of MHN and Three Wire Systems, I would like to thank you again for your interest in the VetAdvisor program and for your commitment to ensuring that our veterans receive the care and services they may need.  I welcome your questions.