Together, Let’s End Their War: Promoting a Culture of Health among Veterans on the Gulf Coast

Background:

Limited availability of culturally-sensitive and effective options for mental health care for military Veterans from all eras represents a major public health issue. Recent wars in Iraq and Afghanistan mark the longest sustained ground combat operations in U.S. history. Roughly 200,000 Veterans are now transitioning annually from military life to civilian roles and responsibilities. Because those who have served in the U.S. Armed Forces comprise a historically low 1 percent of the general population, Veterans in this all-volunteer era shoulder heavy emotional, physical, and spiritual burdens that increase risk for substance abuse, post-traumatic stress, and other health-related conditions. In turn, healthcare leaders throughout the U.S. are struggling to develop equitable solutions to enhance access, delivery, and outcomes of mental health services for Veterans.

Wicked Problem Description:

Despite innovative solutions by the Veterans Health Administration (VHA), most Veterans who struggle with mental health issues do not pursue treatment. In many cases, Veterans turn to alcohol/drugs to manage stress reactions, depression, chronic pain, and other chronic health conditions. In turn, a mutually-reinforcing process can follow that reduces the likelihood of recovery on all fronts. Unfortunately, even when Veterans have access to evidence-based care, they often do not seek help or respond favorably due to self-stigma, poor synchrony with treatment procedures, or lack of long-term supportive care. In turn, poor mental health then perpetuates chronic medical complaints. When such issues are not addressed, Veterans often experience an erosion of resources and connections in life that may partly explain the epidemic of 20 suicides daily in this population.

These issues are magnified in southwest Alabama. Of the half-million people who live within 20-miles of metro Mobile, 10 percent are Veterans. Needs assessment projects conducted by members of the project team suggest 30-50 percent of local Veterans need effective services for substance abuse, post-traumatic stress, depression, and/or suicidal behavior. Yet, almost half of them have not received mental health services since leaving the military.

Project Strategies:

The team will implement a new, cost-efficient strategy to infuse Veteran peer support and community engagement into evidence-based mental health care for Veterans with substance abuse, post-traumatic stress and related issues at Veterans Recovery Resources. Formed by Veterans, for Veterans, Veterans Recovery Resources accelerates Veteran well-being by removing barriers to high-quality, compassionate, and affordable care to create a vibrant community of healthy Veterans, their families and caregivers who support each other over a lifetime, enhancing health, equity, and economic development on the Gulf Coast.

Veterans Recovery Resources offers a continuum of clinically-based services, peer support programming, and community integration activities to provide a Veteran-centered, holistic, and long-term approach to mental wellness. To this end, a phase-based model of recovery is used to (a) reduce unsafe behavior (e.g., substance abuse, self-injurious actions) and promote healthy coping and lifestyle decision-making; (b) work through unresolved traumas/losses as needed (e.g., high impact, evidence-based treatments for post-traumatic stress, such as prolonged exposure); and (c) restore belonging/meaning in life. By establishing a new community of warriors who are willing to commit to a different mission together – that of promoting health and equity in their families, neighborhoods, and local communities – we believe long-term well-being can be achieved.

Outcomes:

Short-term Outcomes:

1. Multiply # Veterans in our community who engage in adequate evidence-based psychosocial treatments for SUDs and co-occurring conditions
2. Augment # Veterans in our community who have the commitment, knowledge and skills to self-manage chronic health conditions via sustained healthy lifestyles
3. Grow the size, cohesion, and reach of the “Veteran Recovery Community” in offering fellowship and preventing relapse to substance abuse and unsafe behavior
4. Expand # Veterans who participate in volunteer and community activities aimed at promoting equity and health
5. Improve number and quality of partnerships among organizations on the Gulf Coast with a shared commitment to promoting Veteran health and well-being

Long-term Outcomes:

• Enhanced Veteran well-being and active, lifelong recovery from substance abuse, post-traumatic stress and co-occurring conditions
• Improved culture of health and health equity on the Gulf Coast

Timeline:

Year 1:

• Begin providing interdisciplinary services to Veterans at Veterans Recovery Resources outpatient clinic
• Conduct Veteran in-take and follow-up processes
• Implement electronic health records system to measure outcomes, support 360 diagnosis and culture of health
• Hone list of partnerships with complementary providers and establish mechanism for collaboration to improve Veteran outcomes and extend a culture of health

Year 2:

• Evaluate outcomes with assessment procedures and accordingly refine methods of service delivery for peer support specialists and the interdisciplinary clinical team
• Expand graduate-level student training programs across all disciplines (physical therapy, psychology, occupational therapy, physician assistant, social work, etc.)
• Implement a technology application for maintaining contact with Veterans and their families and tracking long-term outcomes, including at community events
• Develop procedures for recruiting and training Veteran and non-Veteran volunteers to support community integration and recreational activities among recipients of services
• Establish a calendar of community activities at which a culture of health approach can be shared

Year 3:

• Further integrate partnering community providers into weekly clinical meetings to improve Veteran outcomes and extend a culture of health
• Expand and refine peer support specialist model, based on measured outcome assessments
• Assemble community partners to promulgate culture of health approach, noting advances achieved over the last three years
• Conduct comprehensive program evaluation

Partnerships:

The Clinical Scholars — half of whom are Veterans — will implement the innovative and inter-disciplinary program at Veterans Recovery Resources (VRR), a by-Veteran, for-Veteran community-based non-profit organization serving Veterans and their families in southwest Alabama. This includes training other providers, graduate students and volunteers who serve at VRR in delivering services the “VRR Way.” Extended team members include the Veterans Recovery Resources founder and Executive Director, John Kilpatrick, a 32-year military Veteran and Josh Moore, an 8-year Veteran who provides full-time operational support at the outpatient clinic.

Evaluation Strategies:

Beginning with a baseline assessment, Veterans will be assessed at 3- to 6-month intervals via traditional means (e.g., phone calls) and the creative use of technology (e.g., SMS messaging). Information from these assessments will be used to: (1) develop care plans responsive to Veterans’ preferences, values, and needs; (2) track progress in recovery journeys and responses to care; and (3) continually improve Veteran satisfaction and quality of services. We will rely on psychometrically-validated instruments that capture targeted indices of physical, psychological, relational, and spiritual health.

Tracking outcomes over the months/years after treatment completion will aid peer support specialists in providing support, problem-solving, and feedback. In turn, this practice-based evidence might enhance our services as well as advance the knowledge base about strategies for overcoming this wicked problem in other regions of the country.