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Healing Invisible Wounds: Programs Help Rural Vets with PTSD and Depression

by Candi Helseth

By 2008, nearly 20 percent of military service members nationwide had returned from Iraq and Afghanistan reporting symptoms of PTSD (post traumatic stress disorder) or major depression, according to the report,Invisible Wounds of War. Yet, only slightly more than 50 percent have sought treatment.

Many of these veterans are returning to rural areas where health care resources are limited or even non-existent, requiring them to travel great distances for care.

“It is a true loss to society when the combat veteran is not transitioned and welcomed back home after the battle is done,” said Navy veteran Kevin Williams, a peer specialist with the Virginia Wounded Warrior Program (VWWP). “I’ve encountered a lot of veterans, and they all want the same things when they come home: a job, health care and a safe place to live, and the compensation and benefits of service that they were promised.”

In January 2011, President Barack Obama pledged the support of the federal government for increased behavioral health care services through prevention-based alternatives and integration of community-based services through the Strengthening Our Military Families initiative.

Also in 2011, VA Secretary Eric K. Shinseki participated in a Listening and Walking Tour, visiting veterans in North Dakota, Montana, and Alaska. As part of the initiative, the VA pledged to expand outreach clinics, Vet Centers, and mobile Vet Centers in order to reach more rural veterans, in addition to the $500 million it had given the VA Office of Rural Health (ORH), to fund more than 500 projects.

State Programs Reach Rural Areas in Virginia and Montana

In southwest Virginia, veterans seeking assistance at a VA hospital are likely to drive at least two hours over mountainous roads. With 25 HRSA rural-designated counties and a population density of only 76 persons per square mile, lack of health care access is a major barrier. After securing a three-year, $300,000 per yearHealth Resources and Services Administration (HRSA) Flex Rural Veterans Health Access Program(RVHAP) grant, VWWP Region 3 hired additional staff to coordinate provision of clinical mental health and Traumatic Brain Injury (TBI) services in the local communities. Grant funding also helps provide care coordination to VA facilities when local professionals refer veterans outside the community for medical care.

“The grant has really helped us put more staff into our local communities where we’re not blessed with some of the resources available in bigger areas,” Region 3 Director Matthew Wade said.

“Our resource specialists work one-on-one with vets to identify what resources they can access in our region. If veterans need resources outside the community, we work with other providers, such as bus companies, to arrange transportation.”

All five VWWP regions focus on community-based care, providing an array of services such as mental health screenings, referrals for PTSD and TBI, individual case management and care coordination, substance abuse identification and treatment, peer and family support groups, mental health community education and linkage to VA benefits. The statewide web site also provides planned interactions for veterans to connect and support one another.

Regions have individual autonomy, developing programs specific to needs in their area. Examples of services that vary by region include Equestrian therapy, couple’s retreat weekends to rebuild marriages, and group social activities such as gardening, hunting and social outings.

Coordinated by the Department of Veterans Services, VWWP is a statewide program approved for funding in 2008 by the Virginia General Assembly. VWWP prioritizes assessment and treatment for combat stress related issues and TBI through community-based partnerships and services for veterans and active members of the Virginia National Guard and Reserves. Family support, employment and housing are also among program components.

“The beauty of bringing these services into the local community and working with the community service boards (behavioral health providers) is that these are the clinical treatment programs for people with behavioral health needs,” VWWP Special Projects Coordinator Martha Mead said. “So they are likely to hear about or recognize issues these veterans may be having when they are back in their communities.”

Mead works from the statewide office, which appropriates state funding to the regions and oversees regional activities. In fiscal year 2011, VWWP connected 3,617 Virginia veterans and families to direct behavioral health services. VWWP staff also provided public education and community outreach at 615 locations, reaching more than 20,000 Virginians, including interactions with 6,550 military personnel and families.
Williams estimates it takes VWWP 12 to 18 months to help traumatized veterans make a successful transition back home. “Our program is really about taking the time to listen to the vet and provide the road map and support tools to jump start them along,” he said.

In Montana where a three-year, $300,000 per year RVHAP grant went into effect in October 2010, the “Increasing Service to Montana’s Veterans through Training, Team Building and Technology” program has already achieved several successes. Enrollment for veteran’s assistance has increased to more than 40 percent compared to nationwide statistics in the 30 to 35 percent range. A social media campaign specific to suicide prevention reached 21,000 vets. More than 3,000 requested information and assistance. Active partnerships have been established between the various military branches, the Department of Health and community health providers.

The grant targets 15 counties where Indian reservations account for nearly one-third of the land and the overall population density of veterans is double the national average, according to Project Manager Deb Matteucci. Project goals are three-pronged: training, team building and technology placement.

Training engages a variety of groups. For instance, law enforcement and/or rural emergency medical service units typically are the first responders to emergency calls there, Matteucci said. These providers are being taught to recognize combat-related symptoms and, when appropriate, refer veterans to VA assistance rather than placement in the law enforcement system. RVHAP grant funds are also bringing together entities such as the Montana statewide suicide prevention program, Veterans Affairs, Critical Access Hospitals (CAHs) and community mental health providers in partnerships to collaborate care and provide treatment closest to the veteran’s home.

“We only have one VA hospital in the state so it’s important that veterans can be treated in their home communities,” Matteucci said. “Training has been our first priority. Rural providers need education to help them recognize and treat combat-related symptoms, which can be very different from the usual crises in these remote areas.”

While Montana is successfully using telehealth for medical treatment in several disciplines, infrastructure is limited and unavailable in many small rural communities, said Deb Matteucci., Project Manager for a Montana veterans program. Future plans, Matteucci said, call for CAHs in the grant region to become the hub for community resources and access to telemedicine support to the VA and major state medical centers.

Indiana (see Telepsychiatry Fills Gaps in PTSD Care, Virginia and Montana are among several states that have implemented programs to improve health care access and services for rural veterans. However, the Veterans Health Administration Office of Rural Health (ORH) 2012-2014 Strategic Plan states that 15 percent of soldiers returning from Operation Enduring Freedom and Operation Iraqi Freedom are estimated to have at least one service-connected disability and research demonstrates that rural veterans with mental health needs do not receive care comparable to urban veterans. Apparently, much still remains to be done to assure that veterans who proudly served their country are, in turn, being treated for the mental and physical wounds they incurred in the process.