May 2008 – The Department of Veterans Affairs (VA) has developed special programs to serve the nation’s newest veterans — the men and women who served in Iraq and Afghanistan — by assisting them with a smooth transition from active duty to civilian life. VA’s goal is to ensure that every seriously injured or ill serviceman and woman returning from combat receives easy access to benefits and world-class service fostering recovery, rehabilitation, and reintegration. Their contact with VA often begins with priority scheduling for care and, for the most seriously wounded, VA counselors visiting their bedside in military wards before separation to ensure their VA disability payment coverage will be ready the moment they leave active duty.
Approximately 800,000 Discharged Troops Eligible for VA Care
Of the 1.6 million troops who have served in Iraq and Afghanistan since beginning of the conflicts, 799,791 have been separated from active duty and as civilians routinely became eligible for VA care. Some 299,585 had used VA health services as of the end of fiscal year 2007. These patient numbers reflect the significant presence of National Guard and Reserve members serving, with the breakdown of health-care users including 147,508 Reserve or National Guard members released from federal activation versus 152,077 former regular active duty service members.
Benefits and Outreach
For five years after their discharge, combat veterans have special access to VA health care, even those who have no service-connected illness. Veterans can become “grandfathered” for future access by enrolling with VA during this period. This covers not only regular active-duty personnel who served in Iraq or Afghanistan, but also Reserve or National Guard members who served in the combat theaters. Veterans with service-related injuries or illnesses always have access to VA care for the treatment of their service disabilities without any time limit, as do lower-income veterans. VA offers care through more than 1,400 hospitals, outpatient clinics, nursing homes and counseling centers. Additional information about VA medical eligibility is available at http://www.va.gov/healtheligibility.
In addition to the special medical eligibility, VA’s broad range of benefits include disability compensation, pension, vocational rehabilitation and employment, education, home loan guaranties, automobile and specially adaptive equipment grants, home modification programs for the disabled, life insurance, traumatic injury protection, and survivor benefits. Information about these programs is available at http://www.vba.va.gov/benefit_facts/index.htm
VA has an ambitious outreach program to ensure separating combat veterans know about these VA benefits. Each veteran with service in Iraq or Afghanistan receives a letter from Secretary of Veterans Affairs Dr. James B. Peake after discharge introducing the veteran to VA and its benefits and providing phone numbers and Web sites for more information.
As with all military members, transition briefings prior to discharge acquaint servicemembers with benefits, as do additional pamphlet mailings following separation, and VA has developed brochures, wallet cards and videos. VA conducts briefings at town hall meetings, family readiness groups and during unit drills near the homes of returning Guard and Reserve members. Because of the large number of Reserve and Guard members mobilized in this conflict, VA has made a special effort to work with their units to reach transitioning service members at demobilization sites. To help the governors of each state, VA has trained recently returned veterans to serve as National Guard Bureau liaisons employed by each state to assist their fellow combat veterans.
In 2008, VA launched an effort to track down and contact 550,000 of these veterans who have never used VA care to again remind them about their benefits, including the 5-year eligibility period expansion from three years under 2007 legislation. Another 17,000 current VA users who were sick or injured while serving in Iraq or Afghanistan will be contacted and VA will offer to appoint a care manager to work with them if they don’t have one already.
“Seamless Transition” Liaisons for the Severely Wounded
To assist wounded military members and their families, VA has placed workers at key military hospitals where severely injured servicemembers from Iraq and Afghanistan are frequently sent. These include benefit counselors who help the servicemember obtain VA services as well as social workers who facilitate health care coordination and discharge planning as servicemembers transition from military to VA care. Under this program, VA staff members serve at Walter Reed Army Medical Center in Washington, D.C.; National Naval Medical Center in Bethesda, Md.; Eisenhower Army Medical Center at Ft. Gordon, Ga.; Brooke Army Medical Center and Center for the Intrepid at Ft. Sam Houston, Texas; Madigan Army Medical Center at Tacoma, Wash.; Darnall Army Medical Center at Ft. Hood, Texas; Evans Army Hospital at Ft. Carson, Colo.; Womack Army Medical Center at Ft. Bragg, N.C.; and Balboa Naval Medical Center and Camp Pendleton Naval Medical Center in San Diego.
VA and the Department of Defense (DoD) have improved collaboration and communication. VA employees based at military treatment facilities brief service members about VA health benefits, disability compensation, vocational rehabilitation and employment. Coordinators at each VA benefits regional office and VA medical center work both with the outbased VA counselors and with military discharge staff to ensure a smooth transition to VA services at locations nearest to the veteran’s residence after discharge. At the VA facilities serving the veteran’s home town, the hospital is alerted when the seriously wounded servicemember is being discharged so that the continuity of his or her medications and therapy is ensured when arriving home.
Responding to the top recommendations of the President’s Commission on Care for America’s Returning Wounded Warriors, co-chaired by former Sen. Robert Dole and former Health and Human Services Secretary Donna Shalala, VA and DoD established a new recovery coordinators office and deployed workers to key military treatment facilities. Their job cuts across bureaucratic lines and reaches into the private sector as necessary to identify services needed for the rehabilitation of the seriously wounded and ill service member or veteran or to aid their family. Participating patients may include those with seriously debilitating burns, spinal cord injury, amputation, visual impairment, traumatic brain injury and post-traumatic stress disorder. These recovery coordinators are in addition to 105 patient advocates VA has put in place since June 2007 to ensure a smooth transition of wounded service members through VA’s health care system while also cutting red tape for other benefits.
Medical Conditions of Combat Veterans
Patterns of illness shown in diagnoses of recent combat veterans who have come to VA for care have not suggested significant differences from the types of primary care, chronic conditions or mental health issues seen in earlier combat veterans. However, careful studies will be required to draw appropriate comparisons using control groups of similar veterans, representative samplings, and other scientific methods. An early neurological study tested 654 Army veterans before deployment to Iraq in 2003 and again after returning in 2005, finding mild impairments in memory and attention lapses, but significantly faster reaction times when compared to other veterans not deployed to the theater. These warrant further investigation. VA also is analyzing combat veterans’ deaths from diseases and accidents in hopes of publishing mortality studies in the future.
Nationally automated data from VA’s payment system for service-connected diseases and disabilities does not distinguish between combat-related injuries and those incurred or worsened while the service member was in non-hostile locations. Some of the most common service-connected conditions among those who served at some point in the Iraq and Afghanistan theaters include musculoskeletal conditions and hearing disorders.
Polytrauma Centers Provide Specialized Care
Improvised explosive devices and rocket-propelled grenades often result in devastating injuries, including amputations, sensory loss and brain injury. Modern body armor and advances in front-line trauma care have enabled combat veterans to survive severe attacks that in prior wars were fatal. In response to the demand for specialized services, VA expanded its four traumatic brain injury centers in Minneapolis, Palo Alto, Richmond and Tampa to become polytrauma centers encompassing additional specialties to treat patients for multiple complex injuries. VA is building a fifth major center in San Antonio. The existing centers are supplemented by 17 polytrauma network sites and polytrauma clinic support teams around the country providing state-of-the-art treatment closer to injured veterans’ homes.
Polytrauma centers treat traumatic brain injury alone or in combination with amputation, blindness, or other visual impairment, complex orthopedic injuries, auditory and vestibular disorders, and mental health concerns. VA has added clinical expertise to address the special problems that the multi-trauma combat injured patient may face. This can include intensive psychological support treatment for both patient and family, intensive case management, improvements in the treatment of vision problems, and rehabilitation using the latest high-tech specialty prostheses. Polytrauma teams bring together experts to provide innovative, personalized treatment to help the injured service member or veteran achieve optimal function and independence.
The polytrauma network sites are supported by a polytrauma telehealth network, which allows remote clinical and educational activities by way of state-of-the-art videoconferencing capabilities. This ensures that specialty expertise is available throughout the system of care and that care is provided at a location and time that is most accessible to the patient.
VA’s polytrauma centers had treated 487 veterans of the war in Iraq and Afghanistan through fiscal year 2007.
Traumatic Brain Injury
Because brain injury is recognized as the signature injury of the current conflict, VA launched an educational initiative to provide its clinicians a broad base of knowledge with which to identify potential traumatic brain injury patients, mechanisms for effective care, and a better understanding of patients who experience this condition. VA has made training mandatory for physicians and other key staff in primary care, mental health and rehabilitation programs.
Traumatic brain injury (TBI) can be caused without any visible injuries when explosives jar the brain inside the skull. Symptoms can range from headaches, irritability, and sleep disorders to memory problems and depression. When a combat veteran from the current conflict presents for medical care, an alert in VA’s electronic records system prompts clinicians to ask if the veteran ever lost consciousness in the combat theater, beginning a series of screening questions designed to identify those at risk of undetected TBI for referral and a thorough workup. Early estimates indicate a third of the veterans who screen positive are ultimately found to have suffered a traumatic brain injury, representing less than six per cent of all combat theater veterans screened, but VA believes it is an important approach to improve detection of mild TBI that may otherwise go unrecognized. More data will need to be analyzed over time to gather a true picture of prevalence of mild TBI.
The more serious TBI patients may be treated in VA’s polytrauma centers. Through the end of fiscal year 2007, 460 of the polytrauma center patients had brain involvement in their injuries.
Mental Health Care and Post-Traumatic Stress Disorder
About one-third of these combat veterans who seek care from VA have a possible diagnosis of a mental disorder, and VA has significantly expanded its counseling and mental health services. VA has launched new programs, including dozens of new mental health teams based in VA medical centers focused on early identification and management of stress-related disorders, as well as the recruitment of about 100 combat veterans in its Readjustment Counseling Service to provide briefings to transitioning servicemen and women regarding military-related readjustment needs.
In less than a year of operation, a new suicide hotline operated by VA at 800-273-TALK (800-273-8255) had received 37,200 calls and recorded 720 “rescues,” or prevented suicides. VA’s suicide hotline is available 24 hours a day, seven days a week, to help any veteran in need. In addition, VA has suicide prevention coordinators at each of its medical centers.
VA’s Environmental Epidemiology Service is engaged in a study of the causes of death of veterans who have served in Iraq and Afghanistan, including suicide. From the beginning of the war through the end of 2005 there were 144 known suicides among these new veterans. This number translates into a rate that is not statistically different from the rate for age, sex, and race matched individuals from the general population. Nevertheless, VA takes the position that one suicide among those who have served their country is too much and it emphasizes suicide prevention activities. To decrease instances of suicide, VA is providing enhanced access to high quality mental health care in conjunction with prevention programs, ranging from from training VA employees about suicide risk factors and warning signs to setting an access standard of screening those who present with any mental health issue in less than 24 hours. Altogether, VA has more than 200 mental health providers whose jobs are specifically devoted to preventing suicide among veterans.
Many of the challenges facing the soldiers returning from Afghanistan and Iraq are stressors that have been identified and studied in veterans of previous wars. VA has developed world-class expertise in treating chronic mental health problems, including post-traumatic stress disorder (PTSD). Post-traumatic stress involves a normal set of reactions to a trauma such as war. Sometimes it becomes a disorder with the passage of time when feelings or issues related to the trauma are not dealt with and are suppressed by the individual. This can result in problems readjusting to community life following the trauma. Since the war began, VA has activated dozens of new PTSD programs around the country to assist veterans in dealing with the emotional toll of combat. In addition, 209 “vet centers” provide easy access to readjustment counseling in consumer-friendly facilities apart from traditional VA medical centers.
One early scientific study estimated the risk for PTSD from service in the Iraq war was 18 percent, while the estimated risk for PTSD from the Afghanistan mission was 11 percent. Data from multiple sources now indicate that approximately 10 to 15 percent of soldiers develop PTSD after deployment to Iraq and another 10 percent have significant symptoms of PTSD, depression or anxiety and may benefit from care. Alcohol misuse and relationship problems add to these rates. Combat veterans are at higher risk for psychiatric problems than military personnel serving in noncombat locations, and more frequent and more intensive combat is associated with higher risk. With military pre- and post-deployment health assessment programs seeking to destigmatize mental health treatment, coupled with simplified access to VA care for combat veterans after discharge, experts believe initial high prevalence likely will decrease over time.
Studies of PTSD patients in general have suggested as many as half may enjoy complete remission and the majority of the remainder will improve. Research has led to scientifically developed treatment guidelines covering a variety of modern therapies with which clinicians have had success. Treatments range from psychological first aid to a “talking treatment” called prolonged exposure therapy. Cognitive processing therapy is an additional approach. Psychopharmacology may include medications such as Zoloft or Paxil — with newer drugs under studies now in progress.
VA Research Benefits Combat Veterans
VA researchers have developed a comprehensive agenda to develop new treatments and tools for doctors to ease pain, improve access and address the full range of health issues of today’s combat veterans. Some of the current research projects include:
• testing new drugs for treating traumatic brain injuries and new ways to improve memory and attention;
• cutting-edge technology with microelectronics and robotics to create lighter and more functional prostheses that look, feel and respond more like real arms and legs;
• developing a biohybrid limb that combines regenerated tissue, lengthened bone and implanted sensors to harness amputees’ own brain signals so they can better control their artificial limbs; and
• developing new pain treatments to benefit those with severe burns or spinal cord injuries.
Additional Resources
VA Research http://www.research.va.gov
Combat Veterans Information http://www.va.gov/Environagents/page.cfm?pg=16
Polytrauma Centers http://www.polytrauma.va.gov Post-Traumatic Stress Disorder http://www.ncptsd.va.gov Survivors Benefits http://www.va.gov/opa/fact/survivor-benefits.asp
Women Veterans Information http://www.vba.va.gov/bln/21/Topics/Women/
And http://www.va.gov/wvhp/page.cfm?pg=26
