# Presentation: 554193

## Different Wars, Different Risks, Different Outcomes...But Similar Post-Combat Care

***Integrated Post-Combat Care:***
***A Model for Providing Services for Returning Combat Veterans***
***Stephen C Hunt MD MPH***
***Director, Post-Deployment Integrated Care Initiative***
***Katheleen Z Andrews, Co-Director***
***Gordon Schectman MD, Chief Consultant Primary Care***
**Department of Veteran Affairs**

## “The war changed me...

**“****The war changed me...**
**people say I am a different person...**
**my whole life seems off track...”**

## How does combat affect health?

- How are the health affects from the Gulf War
- different from those of other wars?
- How are they similar?
- How do we address the health concerns
- of Gulf War veterans?
- How do we address the health concerns
- of combat veterans in general?

##        Post-war syndromes in the past century1870: Civil War veterans present 			with “irritable heart”1920: WWI veterans present with “shell shock”	“effort syndrome”1950: WWII veterans present with 		“combat fatigue” 1975: Vietnam veterans present with Agent 	Orange exposure, “post traumatic stress 	disorder”                     1995: Gulf War veterans present with Gulf War 	Syndrome (“medically unexplained 	symptoms” 					

##  
    Most Common Disabilities in Veterans

        “How does military service effect health?”	

1.  Scars				4.5%
2.  Skeletal				4.1%
3.  Knee				3.6%
4.  Arthritis due to trauma		3.5%
5.  Tinnitus				3.1%
6.  Hearing loss			3.1%
7.  LS strain				2.9%
8.  PTSD				2.6%
9.  Hypertension			2.5%
10.DDD				2.4%	

-     _**Most Common Disabilities in Veterans**_
**     **
**        ****“****How does military service effect health?”****	**
**1.  Scars****	****	****	****	****4.5%**
**2.  Skeletal****	****	****	****	****4.1%**
**3.  Knee****	****	****	****	****3.6%**
**4.  Arthritis due to trauma****	****	****3.5%**
**5.  Tinnitus****	****	****	****	****3.1%**
**6.  Hearing loss****	****	****	****3.1%**
**7.  LS strain****	****	****	****	****2.9%**
**8.  PTSD****	****	****	****	****2.6%**
**9.  Hypertension****	****	****	****2.5%**
**10.DDD****	****	****	****	****2.4%**

##  
Peacetime Era Veterans
    Most Common Disabilities

“How does military service effect health?”	

1.  Knee				5.4%
2.  Skeletal				5.2%
3.  Arthritis due to trauma		3.9%
4.  Scars				3.8%
5.  LS strain				3.6%
6.  Hypertension			3.3%
7.  Hearing loss			3.2%
8.  DDD				2.9%
9.  Tinnitus				2.8%
10.Hemorrhoids			2.4%	

_**Peacetime Era Veterans**_
-     _**Most Common Disabilities**_
**          **
**“****How does military service effect health?”****	**
**1.  Knee****	****	****	****	****5.4%**
**2.  Skeletal****	****	****	****	****5.2%**
**3.  Arthritis due to trauma****	****	****3.9%**
**4.  Scars****	****	****	****	****3.8%**
**5.  LS strain****	****	****	****	****3.6%**
**6.  Hypertension****	****	****	****3.3%**
**7.  Hearing loss****	****	****	****3.2%**
**8.  DDD****	****	****	****	****2.9%**
**9.  Tinnitus****	****	****	****	****2.8%**
**10.Hemorrhoids****	****	****	****2.4%**

##  
World War II Era Veterans
       Most Common Disabilities

“How did WWII effect combatants?”

1.  Anxiety Disorder			5.3%
2.  Scars				4.7%
3.  Cold injury residuals  		4.0%
4.  Arthritis due to trauma		3.4%
5.  PTSD		   		2.5%
6.  Pes planus				2.4%
7.  Hearing loss			2.9%
8.  Tinnitus				2.3%
9.  Scars				2.2%
10.Head/neck scars			2.3%

_**World War II Era Veterans**_
-        _**Most Common Disabilities**_
**	**
**“****How did WWII effect combatants?”**
**1.  Anxiety Disorder****	****	****	****5.3%**
**2.  Scars****	****	****	****	****4.7%**
**3.  Cold injury residuals  ****	****	****4.0%**
**4.  Arthritis due to trauma****	****	****3.4%**
**5.  PTSD****	****	****   ****	****	****2.5%**
**6.  Pes planus****	****	****	****	****2.4%**
**7.  Hearing loss****	****	****	****2.9%**
**8.  Tinnitus****	****	****	****	****2.3%**
**9.  Scars****	****	****	****	****2.2%**
**10.Head/neck scars****	****	****	****2.3%**

##  
Korean War Era Veterans
       Most Common Disabilities	

“How did the Korean War effect combatants?”

1.  Scars				5.0%
2.  Cold injury residuals		3.9%
3.  Hearing loss			3.0%
4.  Tinnitus				3.0%
5.  Arthritis due to trauma		2.8%
6.  Ulcer, duodenal			2.3%
7.  PTSD				2.2%
8.  Scars       				2.0%
9.  Anxiety disorder			1.9%
10. Skeletal				1.8%

_**Korean War Era Veterans**_
-        _**Most Common Disabilities**_**	**
**“****How did the Korean War effect combatants?”**
**1.  Scars****	****	****	****	****5.0%**
**2.  Cold injury residuals****	****	****3.9%**
**3.  Hearing loss****	****	****	****3.0%**
**4.  Tinnitus****	****	****	****	****3.0%**
**5.  Arthritis due to trauma****	****	****2.8%**
**6.  Ulcer, duodenal****	****	****	****2.3%**
**7.  PTSD****	****	****	****	****2.2%**
**8.  Scars       ****	****	****	****	****2.0%**
**9.  Anxiety disorder****	****	****	****1.9%**
**10. Skeletal****	****	****	****	****1.8%**

##  
Vietnam War Era Veterans
      Most Common Disabilities

“How did the Vietnam War effect combatants?”

1.  Scars				5.6%
2.  PTSD				5.4%
3.  Diabetes				3.9%
4.  Skeletal				3.6%
5.  Hearing Loss			3.4%
6.  Tinnitus				3.1%
7.  Knee				2.9%
8.  Hypertension			2.7%
9.  Arthritis due to trauma		2.6%
10. LS strain				2.3%

_**Vietnam War Era Veterans**_
-       _**Most Common Disabilities**_
**	**
**“****How did the Vietnam War effect combatants?”**
**1.  Scars****	****	****	****	****5.6%**
**2.  PTSD****	****	****	****	****5.4%**
**3.  Diabetes****	****	****	****	****3.9%**
**4.  Skeletal****	****	****	****	****3.6%**
**5.  Hearing Loss****	****	****	****3.4%**
**6.  Tinnitus****	****	****	****	****3.1%**
**7.  Knee****	****	****	****	****2.9%**
**8.  Hypertension****	****	****	****2.7%**
**9.  Arthritis due to trauma****	****	****2.6%**
**10. LS strain****	****	****	****	****2.3%**

##  
Gulf War Era Veterans
    Most Common Disabilities

“How did the Gulf War effect combatants?”	

1.  Skeletal				6.4%
2.  Knee				4.8%
3.  Arthritis due to trauma		4.5%
4.  LS strain				4.3%
5.  Tinnitus				4.0%
6.  Scars				3.4%
7.  DDD				3.2%
8.  Hypertension			3.0%
9.  Hearing Loss			2.9%
10. Ankle				2.3%

_**Gulf War Era Veterans**_
-     _**Most Common Disabilities**_
**“****How did the Gulf War effect combatants?”****	**
**1.  Skeletal****	****	****	****	****6.4%**
**2.  Knee****	****	****	****	****4.8%**
**3.  Arthritis due to trauma****	****	****4.5%**
**4.  LS strain****	****	****	****	****4.3%**
**5.  Tinnitus****	****	****	****	****4.0%**
**6.  Scars****	****	****	****	****3.4%**
**7.  DDD****	****	****	****	****3.2%**
**8.  Hypertension****	****	****	****3.0%**
**9.  Hearing Loss****	****	****	****2.9%**
**10. Ankle****	****	****	****	****2.3%**

## Table 6.  Frequency of Major ICD-9 Diagnostic Categories Among Gulf War Veterans          

                                                                                                     VA Registry             VA Registry                                                               
                                                                                  Initial Format       Revised Format      DoD’s CCEP
                                                                                      (n = 49079)          (n = 21306)               (n = 32876)
ICD-9 Code                                                              %  (Number)         % (Number)            % (Number)                       

290 – 319 Mental Disorders    		  15.0  (7345)           35.7  (7615)            48.4 (15923)
320 – 389 Nervous System/Sense Organs                 8.2 (4049)             17.9 (3805)	   19.4  (6369)
460 – 519 Respiratory System                                 14.2 (6966)             18.4 (3926)             19.0 (6253)
520 – 579 Digestive System                                      11.3 (5569)             17.7 (3773)             24.0 (7896)             
680 – 709 Skin and Subcutaneous Tissue               13.4 (6562)             19.6 (4167)             21.4 (7051)
710 – 739 Musculoskeletal/Connective Tissue       25.1 (12328)           39.4 (8404)             70.0 (23012)
780 – 799 Symptoms, Signs, and Ill-Defined            3.2 (1552)             16.2 (3451)             63.8 (20982)

*    Used for a diagnosis of “healthy” (V65.5) among CCEP participants
+    “Complications of Pregnancy, Childbirth, and the Puerperium,” “Congenital Anomalies,”  and “Certain Conditions Originating in the Perinatal Period”
++  Not included in this entry are 1131 individuals evaluated in the revised VA registry who were given a special diagnostic code for a diagnosis of chronic fatigue                                              
      syndrome, sleep apnea, or fibromyalgia.

				Combined analysis of the VA and DoD Gulf War Clinical Evaluation Programs
				DVA/VHA and DoD (Office of the Assistant Secretary of Defense, Health Affairs)
				September 2002

- _                                                                                                                                                                         _
_**                                                                                                     **__**VA Registry             VA Registry                                                               **_
_**                                                                                  **__**Initial Format       Revised Format      DoD’s CCEP**_
_**                                                                                      **__**(n = 49079)          (n = 21306)               (n = 32876)**_
_***ICD-9 Code                                                              ***__**%  (Number)         % (Number)            % (Number)                       **_
_**   **_
_**290 – 319 **__**Mental Disorders**__**    **__**	**__**	**__**  **__**15.0**__**  (7345)           **__**35.7**__** **__** (7615)            **__**48.4**__** (15923)**_
_**320 – 389 **__**Nervous System/Sense Organs**__**                 8.2 (4049)             **__**17.9**__** (3805)**__**	**__**   **__**19.4**__** **__** (6369)**_
_**460 – 519 **__**Respiratory**__** System                                 14.2 (6966)             **__**18.4**__** (3926)             **__**19.0**__** (6253)**_
_**520 – 579 **__**Digestive**__** System                                      11.3 (5569)             **__**17.7**__** (3773)             **__**24.0**__** (7896)             **_
_**680 – 709 **__**Skin**__** and Subcutaneous Tissue               13.4 (6562)             **__**19.6**__** (4167)             **__**21.4**__** (7051)**_
_**710 – 739 **__**Musculoskeletal**__**/Connective Tissue       **__**25.1**__** (12328)           **__**39.4**__** (8404)             **__**70.0**__** (23012)**_
_**780 – 799 **__**Symptoms, Signs, and Ill-Defined**__**            3.2 (1552)             **__**16.2**__** (3451)             **__**63.8**__** (20982)**_
_***    Used for a diagnosis of “healthy” (V65.5) among CCEP participants**_
_**+    “Complications of Pregnancy, Childbirth, and the Puerperium,” “Congenital Anomalies,”  and “Certain Conditions Originating in the Perinatal Period”**_
_**++  Not included in this entry are 1131 individuals evaluated in the revised VA registry who were given a special diagnostic code for a diagnosis of chronic fatigue                                              **_
_**      **__**syndrome, sleep apnea, or fibromyalgia.**_
**	****	****	****	****Combined analysis of the VA and DoD Gulf War Clinical Evaluation Programs**
**	****	****	****	****DVA/VHA and DoD (Office of the Assistant Secretary of Defense, Health Affairs)**
**	****	****	****	****September 2002**

##  Veterans from Iraq/Afghanistan deployment

		Seen at VA by 3-31-08		N=347,750					          (40% of 868,717)

Diagnoses:	Musculoskeletal		47.6%
			Mental disorders	42.5%
			Symptoms/signs		39.7%
			Nervous system		34.9%
			GI			31.8%		
			Respiratory		20.4%
			Endocrine/Nutrition	21.8%		
			Injury/Poisoning	21.2%

VHA Office of Public Health and Environmental Hazards
August 2008

**	****	****Seen at VA by 3-31-08****	****	****N=347,750****	****	****	****	****	****          (40% of 868,717)**
**Diagnoses:****	****Musculoskeletal****	****	****47.6%**
**	****	****	****Mental disorders****	****42.5%**
**	****	****	****Symptoms/signs****	****	****39.7%**
**	****	****	****Nervous system****	****	****34.9%**
**	****	****	****GI****	****	****	****31.8%****	****	**
**	****	****	****Respiratory****	****	****20.4%**
**	****	****	****Endocrine/Nutrition****	****21.8%****	****	**
**	****	****	****Injury/Poisoning****	****21.2%**
**VHA Office of Public Health and Environmental Hazards**
**August 2008**

##  
Table 4.  Self-reported Health Status of Gulf War Veterans
____________________________________________________________________________________
                         VA Registries                                                             DoD CCEP
		             Initial Format               Revised Format
Scale                        % (number)                   % (number)                             Scale                    % (number)
________________________________________________                       ________________________
Very good                 5.3     (2,559)	            5.6  (1,196)                             Excellent              5.6     (485)
Good                       24.6    (11,935)	          26.4  (5,632)                             Very good          21.0   (1,833)
Fair                         41.6    (20,170)              42.0  (8,957)	                  Good                  41.0   (3,610)
Poor                        23.4    (11,327)              20.6  (4,399)                              Fair                    26.0  (2,261)
Very poor                  5.2      (2,501)               5.3  (1,122)                              Poor                      6.0     (522)
____________________________________________________________________________________
  * 	Data on health status were provided by 99% of VA registry participants but by only 35% of veterans evaluated in the CCEP.

				Combined analysis of the VA and DoD Gulf War Clinical Evaluation Programs
				DVA/VHA and DoD (Office of the Assistant Secretary of Defense, Health Affairs)
				September 2002

_**Table 4.  Self-reported Health Status of Gulf War Veterans**_
_**____________________________________________________________________________________**_
_**                         **__**VA Registries                                                             DoD CCEP**_
**	****	**_**             **__**Initial Format               Revised Format**_
_**Scale                        % (number)                   % (number)                             Scale                    % (number)**_
_**________________________________________________ **_**                      ________________________**
_***Very good***__**                 5.3     (2,559)**__**	**__**            5.6  (1,196)                             **__***Excellent  ***__**            5.6     (485)**_
_***Good  ***__**                     24.6    (11,935)**__**	**__**          26.4  (5,632)                             **__***Very good***__**          21.0   (1,833)**_
_***Fair      ***__**                   41.6    (20,170)              42.0  (8,957)**__**	**__**                  **__***Good ***__**                 41.0   (3,610)**_
_***Poor***__**                        23.4    (11,327)              20.6  (4,399)                              **__***Fair***__**                    26.0  (2,261)**_
_***Very poor***__**                  5.2      (2,501)               5.3  (1,122)                              **__***Poor ***__**                     6.0     (522)**_
_**____________________________________________________________________________________**_
_**  **__*** **__**	**__**Data on health status were provided by 99% of VA registry participants but by only 35% of veterans evaluated in the CCEP.**_
**	****	****	****	****Combined analysis of the VA and DoD Gulf War Clinical Evaluation Programs**
**	****	****	****	****DVA/VHA and DoD (Office of the Assistant Secretary of Defense, Health Affairs)**
**	****	****	****	****September 2002**

## The Critical Question...

_**Traditional Medical Model:**_** **
**What is your diagnosis? Are your symptoms caused by X, Y or Z?**
**If we can’t sort it out, do we treat you for X, Y or Z?**
**If we can’t come up with a clear diagnosis, how can we provide you with the support you need?**

## The False Dichotomy in the Medical Model...

_**Gulf War:**_** **
**Are your symptoms from a “real” injury (environmental agent exposure)**
**	****or are they “just” PTSD (“in your head, mental, not “real”, “just stress”)**
_**Iraq/Afghanistan War**_**: **
**Are your symptoms from a “real” injury (blast wave exposure and head injury) or are they “just” PTSD (“in your head, mental, not “real”, “just stress”)**

## Rate the degree to which you believe “Persian Gulf Illness” is:

- Percent

**Richardson RD, Engel CC, McFall, M, McKnight K, Hunt SC. Clinician  Attributions for  Symptoms and Treatment of Gulf War-Related Health Concerns. Archives of Internal Medicine 2001; 161: 1289-1294.**

## Rate the degree to which you believe 

- Percent

**Rate the degree to which you believe **
**“****Persian Gulf Illness,” in general, **
**is most effectively treated by:**

**Richardson RD, Engel CC, McFall, M, McKnight K, Hunt SC. Clinician  Attributions for  Symptoms and Treatment of Gulf War-Related Health Concerns. Archives of Internal Medicine 2001; 161: 1289-1294.**

## The Critical Question...

_**Integrated Post-Combat Care Model**_**: **
**How are you doing? How has your combat experience affected you and your life? What risk exposures/conditions from combat might be contributing to your symptoms?**
**How can we manage your symptoms/conditions, improve your functioning and reduce further impairment?**
**How can we provide you with the support you need to get your health, your family and your life back on track?**

## Health Concerns of Combat Veterans

***What are the ******risks****** of war?***
***Generic risks in all combat***
***Unique risks of each conflict***
***Perform Risk Assessment:***
_**Physical**_
_**Psychological**_
_**Psycho-social**_

## Health Concerns of Combat Veterans

***What are the ******risks****** of war?***
- 	        _**Physical factors**_
**injury****	****	**** ****	****noise **
**temperature****	**** ****	****sleep deprivation **
**diet ****	****	****	****austere conditions **
**toxic agents****	**** ****	****infectious agents**
**immunizations****	****blast wave exposure**

## Health Concerns of Combat Veterans

***What are the ******risks****** of war?***
- 	   _**Psychological factors**_
**anticipation of combat**
**combat trauma****	**
**non-combat trauma (including MST)**
**separation from family/home **
**deprivation/hyper-stimulation**

## Health Concerns of Combat Veterans

***What are the ******risks****** of war?***
- 	   _**Psycho-social factors**_
**Marital/family disruption**
**Financial challenges**
**Vocational impacts**
**Impairments in social networks**

## Risk Assessment: 

**	****“****What factors (exposures, experiences, etc) are present that increase the likelihood of your having particular negative health outcomes?”**
_**Risk Communication:**_** **
**	****“****What are your potential health concerns, given your personal risk factors?”**
_**Risk Management:**_
**	****“****How can we minimize negative health ****	****impacts of combat?”**
**Pre-deployment**
**During deployment**
**Post-deployment**

## What can we say to returning combat veterans?

_**You are at risk for certain health concerns**__**:**_
**1.Hearing loss and tinnitus**
**2.Dental problems**
**3.Musculo-skeletal injuries/physical war wounds**
**4.Environmental agents effects**
**5.Medically unexplained symptoms/general physiological distress**
**6.Effects of psychological trauma**
**7.Iraq/Afghanistan specific concerns: Leishmaniasis/TBI**
**8.Family/marital/work/psychosocial concerns**

## PHQ Somatic SymptomsPost-Combat Symptoms Vary by Conflict

- PHQ Somatic Symptoms**Post-Combat Symptoms Vary by Conflict**

## B: Symptom Attribution Survey

## B: Symptom Attribution Survey

## C: Exposures	

## D: Combat Exposure

## E: Non-combat exposures

## F: PHQ and K: PCL-M

- Total PCL score 33(OIF/OEF) vs. 29 (Gulf)

## G: SF-36

## Table 5. Perceived Barriers to Seeking Mental Health Services among All Study Participants (Soldiers and Marines).  From:   Hoge: N Engl J Med, Volume 351(1).July 1, 2004.13-22

**Table 5**. Perceived Barriers to Seeking Mental Health Services among All Study Participants (Soldiers and Marines).  *From:*   Hoge: N Engl J Med, Volume 351(1).July 1, 2004.13-22

## Barriers to Accessing MH Care (N=92)

##  Veterans from Gulf War 
(deployed to conflict)

Enrolled in VA		248,008 
				         (40% of 618,283)
Using Vet Centers 	              83,913 
				        (13.6% of 618,283)
Claims granted SC                210,697
				        (34.1% of 618,283)
SC for Undiagnosed	                 3,381
	Illness		           ( .5% of 618,283)

Gulf War Veterans Information System
February 2008

**(deployed to conflict)**
**	****	**
**Enrolled in VA****	****	****248,008 **
**	****	****	****	****         ****(40% of 618,283)**
**Using Vet Centers ****	****              83,913 **
**	****	****	****	****        ****(13.6% of 618,283)**
**Claims granted SC                210,697**
**	****	****	****	****        ****(34.1% of 618,283)**
**SC for Undiagnosed****	****                 3,381**
**	****Illness****	****	****           ****( .5% of 618,283)**
**Gulf War Veterans Information System**
**February 2008**

## 			 What Can We Do as a Treatment Community

- 			 What Can We Do as a Treatment Community
-                                to Best Help Those Who Are Experiencing
-                                 Health Affects of War?_** **_

## Gulf War Veterans’ Clinic PhilosophyBeliefs

**There are symptoms and health problems which  have arisen subsequent to service in the Gulf.**
**Some symptoms may be related to exposures/experiences in the Gulf.**
** ****Symptoms can affect all aspects of life.**

## Beliefs 

**Psychological trauma and environmental exposures can lead to psychological, emotional and physical changes in the body.  There is no mind/body dualism. **
**We may never fully understand the  complex relationships between exposures/experiences  and symptoms.**

##  Beliefs 

**Guesses and unproven theories regarding etiologies can be confusing and harmful.**
**The search for truths and understanding must continue to be a priority.**
**We do not need to fully understand the causes of symptoms to effectively manage them.**

## Gulf War Veterans’ Clinic Philosophy Goals

**Maximize health and overall functioning.**
**Symptom management not symptom eradication.**
**Improve quality of life, not cure of disease**

## Gulf War Veterans’ Clinic Philosophy Methods

**health focus not disease focus**
**clear, open communication/easy access**
**continuity in providers and care**
**regularly scheduled visits**
**integrated approach**
**family oriented care**
**cooperative partnership led by the veteran**

## Goals of Treatment

-   Cooperative Partnership in Rehabilitation
-   treatment efforts are directed towards
-       reducing suffering and disability
-    symptom relief is important, although 	symptoms may continue
-    the presence of symptoms does not mean the 	absence of health

## Premises

The health care risks and health care needs of combat 	veterans differ from those of non-combat veterans.
The health care needs of combat veterans are best 	served by clinicians familiar with the unique health 	risks of combat.
The health care needs of combat veterans are best 	served in a setting utilizing multidisciplinary 	resources and integrated care. 

** **
**The health care risks and health care needs of combat ****	****veterans differ from those of non-combat veterans.**
**The health care needs of combat veterans are best ****	****served by clinicians familiar with the unique health ****	****risks of combat.**
**The health care needs of combat veterans are best ****	****served in a setting utilizing multidisciplinary ****	****resources and integrated care. **

- _Integrated Post Combat Care__ _

##  Management of Post-Combat Health ConcernsIntegrated, interdisciplinary intervention including medical and mental health clinicians, SW, PT, Rehab, who are sensitive to the combat experience.Accessing and utilizing available benefits (C&P, educational, marital/family support)Must involve not only VA/DoD but also include community integration/community organizations 				

##        Management of Health Concerns of   	  	 	    Returning Combat VeteransGoals:Optimal functioning (physical, psycho-emotional		and social)To rejoin non-military life.To rejoin post-combat life.To rejoin those who were not at war.To fully rejoin one’s self and one’s best future.To truly return home...”you do not come home from war, you come 	home with war.”

## Philosophy of Post-Combat Care:
Using the five years of post-combat priority eligibility proactively as  a period for assessment, monitoring and utilization of appropriate resources directed towards optimal recovery, rehabilitation and reintegration into post-combat, non-military life by the end of the five year period.

**Using the five years of post-combat priority eligibility proactively as  a period for assessment, monitoring and utilization of appropriate resources directed towards optimal recovery, rehabilitation and reintegration into post-combat, non-military life by the end of the five year period.**

- _Integrated Care for Returning Combat Veterans__Post Deployment Integrated Care_

##  

 Integrated Post Combat Care

-  Integrated Post Combat Care

**The purpose of the integrated post-combat care is to:**
**  ****Address and support the veteran in all aspects**
**   ****of life  which have been affected by their **
**   ****combat experience (including environmental**
**   ****exposure, TBI, mental health and psychosocial **
**   ****concerns)**
**  ****Provide that support in an accessible and**
**   ****integrated way (working in concert with PTSD/**
**   ****Polytrauma/specialty clinics and outside providers)**
**  ****Provide that support in an ongoing way for as**
**   ****long as it is needed**

**Notes:**
SH

Deployment related health concerns include:

Agent Orange exposure in Vietnam                                   
Environmental agents exposures in the Persian Gulf                                   
Health concerns related to Iraqi Freedom deployment                                   
PTSD (post traumatic stress disorder) related to any deployment                                   
Ionizing radiation exposures during nuclear weapons testing                                   
Cold weather injuries related to service during the Korean War or WWII                                   
Chemical/biological agents exposures involved with Project SHAD                                   
Unexplained medical symptoms following a specific deployment                                   
Any other health concern associated with a specific deployment

DR. HUNT INTRODUCES DR. RASKIND (or DR. McFALL)

## Post Deployment Integrated Care

_**Post Deployment Integrated Care**_
**Clinic is a collaboration between primary care, mental health, social work and support from Polytrauma, Pain/Addictions, specialties, C&P**
** **_**Clinic staff includes:**_
**Clinic coordinator**
**Primary care MD/NP**
**Combat stress specialists (mental health)**
**Psychiatrist / Internist**
**Social Work support**
**Liaison with Polytrauma Clinic, specialty ****	****clinics, external resources**

**Notes:**
SH

Deployment related health concerns include:

Agent Orange exposure in Vietnam                                   
Environmental agents exposures in the Persian Gulf                                   
Health concerns related to Iraqi Freedom deployment                                   
PTSD (post traumatic stress disorder) related to any deployment                                   
Ionizing radiation exposures during nuclear weapons testing                                   
Cold weather injuries related to service during the Korean War or WWII                                   
Chemical/biological agents exposures involved with Project SHAD                                   
Unexplained medical symptoms following a specific deployment                                   
Any other health concern associated with a specific deployment

DR. HUNT INTRODUCES DR. RASKIND (or DR. McFALL)

## Post-Deployment Integrated Care:An Approach to VA Post Combat Care

**What do we say to combat veterans from a combat deployment?**
_**We would recommend a post-combat evaluation:**_
**1.Physical exam, mental health evaluation and social work assessment with attention to pertinent combat related exposures, experiences and psychosocial impacts**
**2.Ongoing care to provide necessary treatment and monitoring for any emerging combat related conditions**
**3.Education regarding available benefits/sources of support for the veteran and his/her family**

##                               “How are you doing? 

**                              ****“****How are you doing? **
**                ****How has your combat experience affected you”**
**Acknowledges the full range of potential impacts of the combat **
**	****deployment on the veterans health and life.**
**Provides a sense of risk exposure: environmental agents,**
**	****psychological/combat trauma, psychosocial factors**
**Provides a sense of symptom load**
**“****We know that there are many exposures and experiences **
**which can occur during a combat deployment that can lead to **
**changes in our health and lives...we are going to be sure to **
**identify and address any problems you may be having as a result **
**of your combat experiences.”**

## Health Concerns of Combat Veterans Risk Assessment

**	****	****	**_**Post-combat  evaluation:**_
**Dates in theater**
**Unit/Location**
**MOS**
**Actual duties**
**Immunizations**
**Environmental exposures**
**Combat exposures**
**Psychosocial factors**
**In-theater concerns**
**Interval concerns/current concerns**
**Possibility of re-deployment**

## Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

_**Using an Integrated Care Model:**_
_**Potential advantages of a post-combat **_
_**evaluation and treatment clinic:**_
**Normalizes the post-combat reintegration experience**
**Utilizes a rehabilitative orientation**
**De-stigmatizes the mental health aspects of care**
**Appreciates the common as well as the unique aspects of military service as an occupation and combat as an environment**
**Acknowledges the veteran’s service**** **

## Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

_**Integrated Care Model:**_
_**Roles and Responsibilities**_
_**Team Responsibilities:**_
**Safety**
**Rapport**
**Accessibility **
**Integration**
**Continuity**
**Commitment to Recovery**** **

## Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

_**Integrated Care Model:**_
_**Roles and Responsibilities**_
_**Primary Care Clinician:**_
**Initial primary contact**
**Risk Assessment/Risk Communication**
**Medical Care: assessment/treatment, preventive, health maintenance**
**Do no harm **** **

## Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

_**Integrated Care Model:**_
_**Roles and Responsibilities**_
_**Mental Health Clinician:**_
**De-stigmatize care**
**Mental Health Care: assessment/treatment, preventive, health maintenance**
**Marital/Family and Psychosocial support**
**Do no harm**** **** **

## Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

_**Integrated Care Model:**_
_**Roles and Responsibilities**_
_**Psychiatric Clinician:**_
**De-stigmatize care**
**Consultation/management**
**Liaison with PTSD inpt/outpt treatment**
**Do no harm **** **

## Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

_**Integrated Care Model:**_
_**Roles and Responsibilities**_
_**Social Work Clinician:**_
**Benefits counseling/support**
**Mental health support**
**Marital/family and psychosocial support**
**Case management**
** **** **

## Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

_**Integrated Care Model:**_
_**Roles and Responsibilities**_
_**Other Team Members:**_
**Benefits counseling/support**
**Specialized care (TBI/Polytrauma, SCI, medical specialty)**
**Spiritual support**
** **** **

##        		   Post-Combat CareFor our communities, our medical centers and for each of us individually...How can we best contribute to optimal healing and recovery for those whose lives have been traumatized by war?

##         Integrated Post Combat CareBy welcoming each veteran back to our community, to our VAMC, and saying:Welcome home.We appreciate your service.We want to know how your combat experience affected your health and your life.We want you to know your risk factors and potential health concerns.Let’s get you the resources and assistance 				you need to take care of those 				concerns.We are here for you and your family now... 			and will be here for you in the long run

##      ...we appreciate your service...

**Department of Veteran Affairs **
**Post-Deployment **
**Integrated Care Initiative**
**Stephen C Hunt MD MPH, Director**
**Katheleen Z Andrews MD, Co-Director**
**Gordon Schectman MD, Chief Consultant Primary Care**