# Presentation: 814404

## Impact of the Hurricanes on Veterans with Mental Illness and SubstanceAbuse

*A Market Study on Service Utilization and Unmeet Needs*

## Hurricanes Katrina and Rita

- More than 1700 persons died
- Billions of dollars of damage occurred
- VISN 16- New Orleans and Biloxi: severely affected.

**Notes:**
Discuss our summer strategic planning session:  one common need that kept surfacing was the need to examine the MH patients affected by the hurricane for possible information to guide services and policy. 

## Before the Hurricanes: New Orleans and Biloxi VA Hospitals

- Served more than 88,000 veterans in FY 2004
- More than one in five veterans had a primary diagnosis of mental illness or substance abuse.
- New Orleans VAMC hospital is no longer functional
- Psychiatric division of the Biloxi VA (Gulfport Division) was completely destroyed.

## What happened to mentally illveterans in this area?

- How many veterans with MI and SA died in the hurricane
- How many lost their homes, caregivers, or significant others
- Where they are currently living and under what circumstances
- Are they receiving MH care
- What are their current needs

## Study Members

**Principal Investigator: Greer Sullivan, MD**
**Co-Investigators: **
**	****	****	****Ellen Fischer, PhD**
**	****	****	****Dean Blevins, PhD**
**	****	****	****Mary S. Farmer, PhD Candidate**
**Project Director: Kristin Ward, MS**
**VA Database Managers:**
**	****	****	****Teresa Hudson, PhD**
**	****	****	****Rick Owen, MD**
**Survey Development: **
**	****	****	****Dana Perry, MS**

## Study Goals: 

- 1) Determine the current location of veterans with MI and SA diagnosis who were previously being served at the Gulf Coast Facilities.
- 2) Conduct a service utilization survey and  needs assessment of a sub-sample of this group of veterans.

**Notes:**
Yesterday Joe Constans:  Increased incidence of psychiatric disturbance
PTSD (31%)
Depression (30%)
GAD (11%)
Panic disorder (10%)
Hurricane Andrew estimates (Davis et al., 1996)

Kessler, Galea, Jones, & Parker (2006)
Use of cell phones for contacting residents
Access to mental disorder incidence prior to storm
Documented increases in mental disorders
Found suicidal ideation did not increase proportionately
Beliefs in post traumatic growth important moderator

We will look at records from the 12 months prior to August 2005

## Overview of the Study

- Telephone survey
- Experiences during & after hurricanes
- Current health / mental health functioning
- Health beliefs
- Service use since the hurricanes
- Barriers to care
- 200 participants with pre-existing mental illness and/or substance abuse

## Participants

- 200 veterans aged 18 and over as of 8/29/05
- Received services at NO or Biloxi VAMC.
- Resided in affected area at time of hurricanes
- Mental health clinic between August 2004 and August 2005

**Notes:**
LA parishes: Jefferson, Orleans, Plaquemines, St. Tammany, St. Bernard
MS counties: Hancock, Harrison, Jackson

## Methodology: Goal I

- VA database to identify NO and Biloxi MI veterans who are currently receiving:
- Services at NO or Biloxi
- Services at other VISN 16 healthcare facilities
- No VA services since the hurricane

**Notes:**

Goal I:  Determine the current location of veterans with MI and SA diagnosis who were previously being served at the Gulf Coast Facilities.

All Veterans receiving MH care at New Orleans or Biloxi in the 12 months prior to August 2005 will be captured through the Austin database
We will use this administrative data to identify which of these veterans (1) continue to receive services at the New Orleans and Biloxi health care systems, (2) continue to receive services within our VISN, and (3) who have received no VA services since the hurricane.

## Methodology: Goal IISubgroups

- Input to identify subgroups to include in the survey came from:
- 1) Mental health QUERI
- 2) Substance abuse OUERI
- 3) SCVAHCN Mental Health Product line
- 4) Little Rock HSR&D

**Notes:**
Goal II: Conduct a follow-up needs assessment of a sub-sample of this group of veterans. 

Since this market study is to provide information to the VA regarding MH policy and practice: a group of experts worked together to define appropriate subgroups which were more likely to have increased needs and require more VA resources.  

## Methodology: Goal IISubgroups

**Goal I:**  Categories selected
- 	(1)  Serious Mental Illness (SMI) with ICD-9 codes 295-298.
- 	(2)  Methadone maintenance patients
- 	(3) Pre-existing PTSD patients
- 	(4) Participation in an inpatient or outpatient alcohol program.

**Notes:**
Note on #1:  This will include Mental Health Intensive Case Management (MHICM) patients 

We will work with the identified data set from Aim I of the study and create a subset that contains only the categories listed above.

## Methodology: Goal II Purposeful Sample of the Data Set 

- Stratified purposeful sampling: Illustrate characteristics of particular subgroups of interest
- Within the four identified groups: Random purposeful sampling
- Approximately 200 respondents

**Notes:**
#1This will yield respondents who are somewhere within VISN 16 and are “tied into” the VA healthcare system.
#2 Random Purposeful Sample: This adds credibility when the purposeful sample is larger than one can handle. 
Number per group will be portionate to the percentage the group represents from the entire data set.

## Survey Development

- _Demographic Information_
- Age, sex, ethnicity, marital status, education
- _Employment/Income_
- Status at time of Katrina, current status, changes
- _Household Information_
- Living situation pre-hurricanes and now

**Notes:**
(location, structure, household members); extent of damage to home/possessions
Joe Constans Study

## Survey Development

- _Katrina Trauma Severity_
- Stressful events experienced
- Traumas during storm & aftermath
- _Alcohol and Drug Use_
- 	Rand Houston Homeless Study Alcohol and Drug Use questions pre-Hurricane and now

**Notes:**
(location, structure, household members); extent of damage to home/possessions

## Survey Development

- _Health Beliefs_
- 	The Brief Illness Perception Questionnaire. (Broadbent, E., Petrie, K., Main, J., & Weinman, J. , June 2006)
- _Barriers to Care_
- 	A Questionnaire for Assessing Barriers to Healthcare Utilization: Part I (W. Pichert and Vanessa Jones Briscoe, 1997)

## Survey Development

- _Physical Health_
- SF-12 Health Survey
- _Unmet Needs_
- 	Rand San Diego SMI-HIV Study: Unmeet Needs Section
- _Service Utilization_
- 	Rand Houston Homeless Study Service Utilization Study

**Notes:**
(Ware, Kosinski & Keller, 1996)

## Methodology: Goal II  Pilot Survey

- Pilot study in March to test for:
- Acceptability
- Feasibility
- Possible flaws.

## Methodology: Goal II Interview Procedures

- Initial letters of introduction with an accompanying information sheet provides an “opt-out” postcard.  This will precede phone contact by 2-3 weeks
- During the telephone call oral consent obtained
- The interviews, which are in-depth and structured with some open response items, will last approximately one hour
-  All participants will receive monetary compensation of $25

**Notes:**
Regression analysis will 

Pre-notification letter sent to potential participants, allows opt-out by postcard or phone (wait 3-4 weeks).
Interviewer will call, explain study, answer questions, obtain verbal informed consent.
Survey will be administered as telephone interview (about 1 hour long).
Address will be recorded to mail $20 compensation check

## Security Issues

- New VA security directives
- New requirements for storing any identified data anywhere outside the VA
- Veterans’ names, addresses and SSNs may reside _***only***_*** ***on VA servers.
- The programmer for CATI and the management database will be provided a VA computer at our LR location.

## Timeline

## Final Thoughts

- These respondents will be located all over VISN 16, so your patients could be contacted.
- If you have any questions contact:
- Mary S. Farmer: 501-257-1105
- Kristin Ward:  Project Coordinator 501-257-1236