Our Invisible Heroes:

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Our Invisible Heroes Rural Veterans Access
to Care
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• Presented to the
• American Osteopathic Association
• Rural Health Leaders Seminar
• June 8, 2007
• West Virginia School of Osteopathic Medicine
• Lewisburg, Wert Virginia
• By
• Hilda R. Heady, MSW
• Associate Vice President for Rural Health
• West Virginia University
• 2005 President,
• National Rural Health Association

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The Message

• There is a never-changing role of rural people
  and minorities in the military and they are
  disproportionately represented among veterans
• Community based services vary across the country
  for these rural and minority veterans.
• As rural health advocates and providers we need
  to be concerned about the availability and
  quality of community based services

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• Americans have an ambivalent relationship with
  their military and their veterans

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• To care for him who shall have borne the battle,
  and for his widow, and his orphan.
• Abraham Lincoln
• Second Inaugural Address
• March 4, 1865

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Let those West Virginian hillbillies go get
shot, they wont take me. Unidentified college
student The Washington Monthly/April 1972
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Memorial Day 2005in Huntington, WV

• We heard a man say to his grandson, When you are
  in a crowd of veterans, you are in a crowd of all
  kinds of Americans. Pay attention to that.

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Rural people value service to others and military
service is just another way to serve
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So who are our Veterans?
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Rural America is home to

• One fifth of the Nation's people 59 million, 1
  in 5 live in poverty
• Keepers of natural amenities and national
  treasures
• Stewards of a unique part of American culture,
  tradition, and history.
• 75 of the Nation's land in 2,000 counties
• 75 of the Nations health underserved areas

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SF-36 Physical and Mental Health of Veterans,
Rural VS Urban
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Veterans and Signature Damage (Source Craig
Hyams, Veterans Health Administration)

• Each war has a signature wound
• Military physicians note signature wounds and
  researcher study them
• Many veterans suffer these wounds

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Signature Damage or Wounds

• Medical science learns and benefits from treating
  such wounds over time
• The longer veterans live with such wounds, the
  greater the contribution to the medical science
  knowledge base

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World War I doughboys in the infirmary line
after being gassed
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Traumatic Brain Injury
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Traumatic Brain Injury

• High tech body armor is saving lives and
  resulting in TBI and possibly PTSD
• TBI can present life-long impairments and
  disabilities physical, cognitive, behavioral,
  emotional, and social

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TBI Complications

• Cognitive issues may impact treatment of other
  diseases and injuries
• Cumulative effect as the veteran may experience
  additional TBI or emotional trauma
• TBI and PTSD can go hand in hand
• Potential increased risk of Alzheimers due to
  interaction of the susceptibility gene (ApOE 4)
  and TBI

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TBI Impairments

• Communications disorders
• Cognitive and emotional disturbances
• Motor impairment
• Attention and memory impairment
• Sensory impairment

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TBI Impairments

• Personality and intellectual changes
• Delirium
• Mood disorders
• Psychotic disorders
• Addictive disorders

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TBI Services

• Defense and Veterans Brain Injury Center
• TBI care network to augment VA services
• 10 national centers (9 VA and 1 civilian)
• VHA TBI Case managers network

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Defense and Veterans Brain Injury Center Network
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The Face of the New American Military Family
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African American Women

• Make up 12.7 of US population
• Make up 37.5 of all women serving in the US
  military forces

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ITS NOT YOUR FATHERS VA

• Currently, women make up approximately 15 percent
  of the active force, are serving in all branches
  of the military, and are eligible for assignment
  in most military occupational specialties except
  for direct combat roles.
• By the year 2010, the women veteran population is
  projected to be over 10 percent of the total
  veteran population.
• (Source Center for Women Veterans -
  http//www1.va.gov/womenvet/ )

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Community Based Approaches Need to include
self-help organizations for veterans and their
families
www.woundedwarriorproject.org
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Community based support groups

• Veteran Service Organizations (VSOs)
• Chartered (recognized by Congress and/or VA for
  claims representation)
• Non-chartered
• Organizations with associates groups
• Branch, race, and gender specific groups
• http//www1.va.gov/VSO/index.cfm?templatev
  iew

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Community Based Support

• Easter Seals
• Mental Health Associations
• 12 Step groups
• American Red Cross
• United Spinal Association
• Etc.

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Who provides their care?

• VA hospitals and medical centers
• Vet Outreach Centers
• Community Health Centers
• CBOCs
• Private Providers

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Number of Vet Centers, CBOCs, VAMCs by States
with Highest Veteran Populations
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Number of Vet Centers, CBOCs, VAMCs by States
with Highest Veteran Populations
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Budget Considerations

• Baby Boomer veterans are aging and putting
  pressure on all systems of care
• We are continuing to create veterans
• From 1996 to 2004 the VA experienced an increase
  of vets seeking care by 134
• The VAs budget from 1996 to 2004 increased by 44

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Iraq KIA Disproportionately from Non-metro
counties

• Between March 2003, and January 2007, 27 of the
  3,000 soldiers killed in action in Iraq were
  from non-metro counties, most from counties under
  25,000
• By contrast, 19 of the population 18-55 years of
  age live in 2,396 non-metro counties and 81 live
  in 836 metro counties

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PTSD Study, 1988

• Vietnam Veterans with PTSD
• 15.2 of male Vietnam Veterans
• 8.5 of female Vietnam Veterans
• Estimated number of Vietnam Veterans with full or
  partial PTSD 1.5M

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U.S. Army has begun to Study Mental Health Issues
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Pre and Post Deployment Studies of Iraq Soldiers

• Exposure to combat
• Doubles the rate of PTSD
• Increases major depression
• Substance Abuse
• Impairment in social functioning (family)
• Impairment in ability to work
• Increases use of health care services

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Pre and Post Deployment Studies

• Pre and Post studies showed increase rate of
  mental disorders from 9.3 to 16
• Rate of PTSD directly correlates to intensity of
  wartime experience
• Rates are likely to be understated

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Veterans with Active Mental Health Issues

• 38 lack trust in mental health professionals
• 41 are embarrassed to seek help
• 50 felt seeking help would damaged their careers
• 65 feared being labeled as weak

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Males with Active Mental Health Issues

• 30 male civilians seek treatment
• Less than 20 servicemen seek treatment

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Implications for Families of Veterans

• War related PTSD impairs parenting (long distant
  parenting, emotional distancing, abuse, etc.)
• Rates of suicide of children of PTSD war veterans
  increases (Australian studies showed 3 times
  civilian rates)
• Divorce rates four times average rate for
  civilian population

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The Bottom line.

• VA services are not enoughthere are too many to
  serve and too many are hidden
• The sticking point is skepticism among military
  personnel that the use of mental health services
  can remain confidential.

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And they are aging

• Vietnam era veterans represent the largest
  veteran population at 8.4 million or 31.7 of the
  total veteran population

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Veterans Integrated Service Networks
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• Support Our Troops means more than a yellow
  ribbon bumper sticker on your SVU.
• Hilda R. Heady
• February 26, 2007

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Policy Recommendations by NRHA

• Expand more CBOCs in rural areas through private
  physician practices, rural hospitals, critical
  access hospitals, rural clinics.
• Increase VA contracting with community health
  centers
• Expand the number of TBI case managers to cover
  more rural areas

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Policy Recommendations, cont

• Extend access to Veterans EHRs to non-VA
  providers through direct release and permission
  of the veterans
• Increase Tricare coverage in rural areas
• Provide demonstrations and research through new
  VA Office of Rural Health focused on rural access
  models and joint research with Federal Office of
  Rural Health Policy

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NRHA is working to bring this issue to the
American conscience
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NRHA Efforts for Rural Veterans

• NRHA, with nearly 15, 000 members, was the first
  on March 29, 2001 US Senate Special Committee on
  Aging, Healthy Aging in Rural America testimony
  to include concerns for rural veterans
• April 19, 2004 Congressional staff hearing
  Congressional Rural Caucus
• July 2004 and Feb 2007 Rural Health Policy Board
  passes policy paper on rural veterans as first
  non-VSO organization to do so

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• November 11, 2004 NRHA press on rural veterans
  for Veterans Day
• NRHA leadership delivers national speeches on
  rural veterans since 2004
• January 31, 2006 Press release on TBI and rural
  veterans
• Congressional testimony 2001, 2004, 2005, 2006.

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• Technical Assistance to non-VA health care
  providers responding to VA requests for proposals
• Provides on going support of legislation to
  increase access to health and mental health
  services for rural veterans
• Staff and leadership maintain contact with
  congressional staff and other organizations on
  this issue and provide policy research and data

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What Rural Providers Can Do

• Learn about TBI, PTSD, etc. utilize appropriate
  primary care screening tools
• Remember to interview and care for vets family
  members as they may be his or her only system of
  support and care. Dont forget the rural vets
  family needs also.
• Help spread the word and knowledge about the
  needs of rural veterans

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• Contact your congressional delegation in support
  of legislation to address the needs of rural
  veterans
• Learn about local veteran organizations and other
  local community organizations and the services
  they provide to veterans and their families.
• Include seminars and workshops at your
  conferences on rural vets needs and issues.

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What More Can I Do?

• Join NRHA or a veterans group and get involved
• Shall your knowledge and awareness with
  colleagues in your service area

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