325

The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

Chapter 20

the continuum of care for 

new combat veterans and 

their families: A PUBLIC HEALTH

approach

HAROLD KUDLER, MD*; ALFONSO R. BATRES, PhD†; CHARLES M. FLORA, MSW‡; TERRY C. WASHAM, 

MSSA, LISW§

; MARSHALL J. GOBY, PhD¥; and LAURENT S. LEHMANN, MD¶

INTRODUCTION

A BRIEF OVERVIEW OF THE DEPARTMENT OF VETERANS AFFAIRS

Readjustment Counseling Service: The Vet Centers

Seamless Transition, Care Management, and Social Work

SERVICES FOR VETERANS OF AFGHANISTAN AND IRAQ

NEW PROGRAMS FOR COMBAT VETERANS AND THEIR FAMILIES

The Joint Conference on Postdeployment Mental Health

The Public Health Model for Deployment Mental Health

Post-Deployment Health Re-Assessment: A New Level of Service Integration

Battlemind Training

Extending and Strengthening the Continuum of Care

BEYOND THE DEPARTMENT OF DEFENSE/VETERANS AFFAIRS CONTINUUM

State and Community Partnerships

Key Elements Replicable in Every State

Summary

*Associate Clinical Professor, Department of Psychiatry, Duke University Medical Center, Durham North Carolina; Associate Director, Mental Illness 

Research, Education and Clinical Center, Mid-Atlantic Veterans Integrated Service Network (VISN 6), VA Medical Center, 508 Fulton Street, #166A, 

Durham, North Carolina 27705 

†

Chief Officer and Director, Readjustment Counseling Service, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420 

‡

Associate Director, Readjustment Counseling Service, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420

§

Colonel, Medical Service Corps, US Army Reserve; Military Liaison Coordinator, Office of Seamless Transition, Department of Veterans Affairs, VA 

Medical Center, 10000 Brecksville Road, Brecksville, Ohio 44141

¥

Colonel, US Army (Retired); Team Leader/Supervisory Psychologist, Veterans Affairs Readjustment Counseling Service, Palm Beach Veterans Center, 

2311 10th Avenue North, #13, Lake Worth, Florida 33461; formerly, Reserve Psychology Consultant, Office of The Surgeon General, US Army, Falls 

Church, Virginia

¶

Associate Chief Consultant in Mental Health, Office of Mental Health Services, Department of Veterans Affairs, 810 Vermont Avenue NW, Room 966, 

Washington, DC 20420
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Combat and Operational Behavioral Health

INTRODUCTION

On October 16, 2003, the US House of Representatives Committee on Veterans’ Affairs held a hearing 

on healthcare for veterans, later published as Handoff 

or Fumble? Do DoD and VA Provide Seamless Health Care 

Coverage to Transitioning Veterans?1 Testimony summarized developments to that date, including the push 

for systematic, standardized posttraumatic stress disorder (PTSD) screening and triage for all patients seen 

in Department of Defense (DoD) and Department of 

Veterans Affairs (VA) primary care and mental health 

settings; the release of the DoD/VA Clinical Practice 

Guideline for Management of Post-Traumatic Stress2; 

the placement of VA liaisons in major military medical 

treatment facilities (MTFs); the importance of coordination between medical personnel and chaplains 

in identifying and reaching out to veterans and their 

families; and the need for new information technologies capable of integrating best practices into DoD and 

VA computerized medical record systems. 

A key observation made in this hearing was that 

the VA is the world leader in the care of post-traumatic stress disorder, but its clinical and research programs have primarily been directed towards veterans 

who suffer from chronic PTSD from Vietnam, Korea, 

and World War II. Starting with the first Gulf War and 

gaining momentum with [the attacks of] September 

11 [2001 and] the conflicts in Afghanistan and Iraq, 

the VA is learning to tackle PTSD proactively.2(p40)

Furthermore, it was noted that 

real grunts see post-traumatic stress disorders, not as 

a reaction of a normal person exposed to a very abnormal situation, but rather, as a failure of training, of 

leadership, strength, or, perhaps, character. This is a 

stigma and it’s the single greatest impediment to effective intervention and continuity of care.2(p41)

This observation was subsequently validated by 

Hoge et al in their seminal report, “Combat Duty in 

Iraq and Afghanistan, Mental Health Problems, and 

Barriers to Care,” that appeared in the New England 

Journal of Medicine in July 2004.3 These considerations 

helped set the stage for the ongoing efforts to strengthen and integrate the continuum of care for combat 

veterans and their families across DoD, VA, state, and 

community settings described in this chapter. 

A BRIEF OVERVIEW OF THE DEPARTMENT OF VETERANS AFFAIRS

Although the VA is well known nationally and internationally, it may still be helpful to provide a brief 

description of what the VA is and who it serves. The 

following information is primarily derived from the VA 

Web site, www.va.gov.4

 Established as a cabinet-level 

agency in 1989 succeeding the Veterans Administration, the department is responsible for providing federal benefits to veterans and their families. Its mission 

is inspired by the words of Abraham Lincoln’s second 

inaugural address, delivered in the final days of the 

Civil War: “to care for him who shall have borne the 

battle and for his widow and his orphan.” Headed by 

the Secretary of Veterans Affairs, the VA is the second 

largest of the 15 cabinet departments. The VA operates nationwide programs for healthcare (the Veterans 

Health Administration [VHA]), financial assistance 

(the Veterans Benefits Administration [VBA]), and 

burial benefits (the National Cemetery Administration). In fiscal year 2007, the VA’s spending totaled 

over $80 billion, including $34.9 billion for healthcare 

and $41.5 billion for benefits. 

Of the 24 million American veterans currently 

alive, nearly three quarters served during a war or 

an official period of conflict. About a quarter of the 

nation’s population, approximately 74.5 million, 

are potentially eligible for VA benefits and services 

because they are either veterans, family members of 

veterans, or survivors of veterans. The VHA provided 

healthcare to almost 5.5 million people in 2006, a 29% 

increase since 2001. By the end of fiscal year 2006, 78% 

of all disabled and low-income veterans had enrolled 

for VA healthcare, and 65% of these had received care 

from the VA. The VA provides care at over 1,400 sites, 

including 155 VA medical centers, 872 communitybased outpatient clinics, and 209 community-based 

Vet Centers. Expansion plans will bring the number of 

Vet Centers to 232. Facilities are located in all 50 states 

and in the District of Columbia, Puerto Rico, Guam, 

and the Philippines. VA services also extend over time: 

as of December 2007, VA was providing benefits to 

three children of Civil War veterans and 232 children 

and widows of Spanish–American War veterans. The 

VA also provides medical backup to DoD at times of 

national emergency or disaster. 

The VA is the nation’s largest provider of graduate 

medical education and a major contributor to medical 

and scientific research. Each year about 90,000 health 

professionals train in VA medical centers, and more 

than half of the physicians practicing in the United 

States received some part of their professional education through the VA. The quality of VA medical care 

significantly exceeds that of the Medicare fee-forservice program across a wide range of objective 

performance measures.5
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

Readjustment Counseling Service: The Vet Centers

The Readjustment Counseling Service (RCS), also 

known as the Vet Center system, plays a unique and 

pivotal role in the DoD/VA/state/community continuum of care. RCS was established by Congress in 

1979 because of the recognition that many Vietnam 

veterans still struggled with readjustment problems 

years after that war’s end.6 Vet Centers are communitybased and staffed by small multidisciplinary teams 

of dedicated providers, many of whom are combat 

veterans. Services are available to any veteran who 

served in the military in a combat theater or anywhere 

during a period of armed hostilities. Family members 

are also eligible for Vet Center services, such as support 

for the families of veterans coping with deploymentrelated stress and bereavement counseling services to 

surviving parents, spouses, children, and siblings of 

service members (including federally activated reserve 

and National Guard personnel) who die of any cause 

while on active duty.

To better respond to the needs of the newest generation of US combat veterans, Congress authorized RCS 

to hire and train 100 veterans of Operation Enduring 

Freedom (OEF) or Operation Iraqi Freedom (OIF) 

as global war on terror (GWOT) outreach workers. 

These counselors provide briefings on readjustment 

and VA services to active and reserve component service members after deployment and help enroll new 

veterans in RCS and VA programs once they become 

eligible for services. Their shared military experience 

promotes rapport between GWOT outreach workers and their fellow OEF/OIF veterans, which helps 

greatly to reduce the stigma associated with discussing 

postdeployment problems. 

Vet Centers seek to increase the resilience of new 

combat veterans and their families through early 

intervention. The ultimate aim of these efforts is to 

prevent the development of more chronic postwar 

problems including occupational, marital/family, 

social, financial, or psychological problems. There is 

never a fee or co-pay for RCS services, and veterans 

do not have to be enrolled in VA healthcare to access 

them. Following a tradition of providing “help without hassles,” Vet Centers are designed to decrease the 

stigma that veterans and their families often associate 

with talking about deployment-related issues in traditional healthcare settings by providing a veteran- and 

family-centered approach emphasizing access and 

understanding. These characteristics of RCS have 

recently been featured (and sensitively portrayed) in 

Gary Trudeau’s Doonesbury cartoon series, which depicts the readjustment struggles of a newly returned 

OIF veteran as he works with his Vet Center counselor 

(himself a Vietnam veteran).7

In addition to psychological counseling for combatrelated trauma, RCS services include community 

outreach, case management and referral, supportive 

social services, and counseling for veterans who were 

sexually assaulted or harassed while on active duty. 

Vet Centers play an important role in connecting 

veterans with appropriate VA services. Since the first 

Vet Center opened, more than 2 million veterans have 

been served. Each year, RCS serves more than 130,000 

veterans and provides more than 1 million visits to 

veterans and family members.4

 From the beginning 

of the conflicts in Afghanistan and Iraq through the 

second quarter of fiscal year 2007, Vet Centers had 

contact with over 227,000 OEF/OIF veterans (this 

represents over one quarter of discharged OEF/OIF 

veterans to date). Over 54,000 of these new veterans 

presented directly to Vet Centers, and the remainder 

have been contacted at Post-Deployment Health ReAssessment (PDHRA) programs and through outreach 

efforts conducted primarily at active duty and reserve 

component demobilization sites. 

Seamless Transition, Care Management, and Social 

Work

In August 2003, to ensure that returning OEF and 

OIF combat veterans have timely access to VA care 

following discharge from military service, then-VA 

Secretary for Veterans Affairs Anthony Principi and 

Dr Michael J Kussman, deputy chief in the Office for 

Patient Care Services, undertook an unprecedented 

shift in VA policy. Dr Kussman, a retired Army general 

who had previously commanded Walter Reed Army 

Medical Center (WRAMC), arranged for VA social 

workers to work side-by-side with Army medical 

staff to facilitate the seamless transition of wounded 

veterans to VA medical care.8

 From the beginning of 

OIF, the VBA had stationed VA benefits counselors in 

DoD MTFs to inform wounded service members about 

VA services and help them begin the claims process. 

These benefits counselors could not, however, enroll 

service members for VA healthcare or transfer them to 

VA facilities. A new clinical system was needed that 

would involve VHA staff with the clinical experience 

needed to triage new veterans to the right level and 

location of care. In Dr Kussman’s words: “We just cut 

through the paperwork and got this going.”8(p17)

Within a month, a VA social worker from the Washington, DC, VA medical center was detailed to the new 

VA Seamless Transition Office at WRAMC. In rounding 

with the Army treatment teams, she and the VA social 

workers who took up the same efforts at Brooke, Eisenhower, and Madigan Army medical centers overcame 

the lack of a common computer record system (or even 

a shared set of paper forms) to develop innovative 
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Combat and Operational Behavioral Health

ways to help new veterans access needed VA services. 

One of their findings was that when a veteran was to 

be discharged from the MTF into care at a VA facility, it 

was often difficult to identify the person at the receiving facility responsible for ensuring follow-up. Within 

weeks, VA established a list of seamless transition 

points of contact for administrative issues and seamless transition care managers (usually social workers) 

for clinical issues at every VA medical facility and VBA 

regional office nationwide. Seamless transition workers 

at each VA medical center subsequently enlarged their 

scope of service to become the point of contact for all 

new combat veterans presenting to the VA. The success 

and value of this effort led the VA to develop what is intended to stand as a permanent policy8(p19) on DoD/VA 

care coordination. In January 2005, the VA established 

the Office of Seamless Transition to assist in working 

with the DoD on strengthening transition efforts. 

These transition efforts have continued to expand. 

The VA now has social workers and benefits counselors 

attached to 11 MTFs and the newly created “Center 

for the Intrepid” rehabilitation facility in San Antonio, 

Texas. The US Army surgeon general assigned an 

Army Medical Department soldier to each of the four 

VA polytrauma rehabilitation centers in March 2005 to 

assist all active duty service members and their families with transition issues. The VA has posted Army 

Wounded Warrior (AW2) soldier–family management 

specialists to VA medical centers across the nation. The 

VA also detailed a certified rehabilitation registered 

nurse to WRAMC to assist in the transition of soldiers 

to VA care. In 2006 the VA established a polytrauma 

call center operating 24 hours a day, 7 days a week, 

to help seriously injured service members and their 

families connect with needed care and benefits. The 

VA has formed a partnership with the National Guard 

Bureau that provides for 54 transition assistance advisors, one stationed in each state and territory, to assist 

with transition issues among National Guard members. The VA is working with the Army Manpower 

and Reserve Affairs program on the Army Physical 

Disability Evaluation System improvement initiative. 

These and other efforts, including a 2007 VA conference, “Evolving Paradigms: Providing Health Care to 

Transitioning Combat Veterans,” attended by 250 DoD 

and 1,000 VA participants, have further extended the 

integration of healthcare services and benefits provided by the DoD and VA. 

In March 2007, the Secretary of Veterans Affairs 

authorized a number of additional positions at VA 

medical centers and outpatient clinics to provide 

expanded support for OEF/OIF veterans and their 

families. Each VA medical center has a full-time nurse 

or social worker who serves as an OEF/OIF program 

manager. These program managers are the primary 

coordinators for VA liaisons stationed at MTFs. They 

work with, and manage the activities of, the VA facility 

case managers and points of contact to assure seamless transition for all OEF/OIF service members and 

veterans. Program managers oversee facility outreach 

efforts including PDHRA events to OEF/OIF veterans 

including National Guard and reserve members. They 

work closely with VBA regional offices to track claims, 

and they also assign case managers for all severely 

injured or ill OEF/OIF veterans and others who may 

need or want case management. 

Additionally, 100 transition patient advocates have 

been strategically distributed throughout the 21 veteran integrated service networks to function as ombudsmen for severely injured or ill OEF/OIF veterans 

and their families as they exit the military and enter 

the VA. The transition patient advocate, assigned to 

these service members while they are still at the MTF, 

arranges for the patients and their families to meet 

(virtually) with the treatment team at the receiving 

VA medical center and assists them with transition to 

the new medical center (escorting them when needed) 

and into the VA benefits system.9

 These programs are 

now organized under VA’s Care Management and 

Social Work Service.

Much of the success of this integration is built upon 

VHA Directive 2002-049.10 Enacted September 11, 

2002, it ensured that hospital care, medical services, 

and nursing-home care were made available to recent 

combat veterans for 2 years beginning on the date of 

the veteran’s discharge from military service. In January 2008, the period of service was extended to 5 years. 

During this 5-year period, these veterans are accorded 

high priority for VA care and are never charged a fee or 

co-pay for treatment of any illness that, in the clinician’s 

opinion, is attributable to military service. Veterans are 

encouraged to begin the application process for any 

appropriate service connection so that military-related 

medical problems can be identified and rated for VA 

care to continue after the initial 5 years have elapsed. 

The provisions of VHA Directive 2002-049 ensure that 

recently discharged service members have expedited 

and unambiguous access to VA services. 

In October 2007, the VA and DoD partnered to establish the Joint VA/DoD Federal Recovery Coordination 

Program to further integrate medical and nonmedical 

care and services. This program will focus on recovery, 

rehabilitation, and community reintegration to extend 

the close care coordination between the DoD and VA 

and across the lifetime continuum of care for severely 

injured service members, veterans, and their families. 
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

SERVICES FOR VETERANS OF AFGHANISTAN AND IRAQ

As of February 2008, the DoD reported that 837,458 

OEF/OIF veterans had become eligible for VA services. 

The VA tracks their care through its Environmental 

Epidemiology Service.11 Of these new veterans, 39% 

(324,846) have already registered with the VHA for 

medical services (notably, the total number of OEF/

OIF veterans who have presented for VA healthcare 

at the time of this writing represents only about 6% of 

the VA’s current caseload).

Among the OEF/OIF veterans who have presented to VA medical facilities, the three most 

common health problems are (1) musculoskeletal 

injuries (including serious wounds and injuries 

but primarily joint and back problems commonly 

associated with deployment to the rocky terrains of 

Afghanistan and Iraq); (2) mental health problems; 

and (3) symptoms, signs, and ill-defined conditions. 

This third category is a diagnostic placeholder 

that designates a condition still in the process of 

evaluation. 

Mental health issues reported by OEF/OIF veterans 

who have so far presented for VA care are represented 

in Table 20-1 (note that these numbers reflect only 

OEF/OIF veterans who have presented to VA medical centers and registered for care through the VHA). 

Over 11,000 other OEF/OIF veterans with a possible 

diagnosis of PTSD have presented to Vet Centers but 

not to VA medical facilities. It must be emphasized that 

the table lists provisional diagnoses. In many cases, 

the categories simply represent the results of positive 

screens for mental health diagnoses. Although positive 

screens are strongly suggestive of a diagnosis, they are 

not the same as a diagnosis. The VA has developed a 

“pop-up” clinical reminder within its computerized 

medical record12 that prompts clinicians to screen 

OEF/OIF veterans for a number of mental health 

problems including PTSD, major depression, alcohol 

abuse or dependence, and traumatic brain injury. The 

range and number of mental health diagnoses can 

be expected to shift over time as clinical evaluations 

progress. 

Diagnoses may also shift as some health issues 

improve and others develop. The Walter Reed Army 

Institute of Research (WRAIR) has reported that the 

majority of soldiers diagnosed with PTSD or depression at 7 months postdeployment did not meet criteria 

for either condition during the first month after deployment.13 Given the stigma associated with mental 

health problems in general, and with postdeployment 

mental health problems in particular,3 veterans with 

such problems may be hesitant to discuss them when 

they first present for care. Over time, as a clinician–

patient trust develops and family or social pressure to 

seek help mounts, veterans and their family members 

may become more willing to report such problems. 

Kang and Hyams14 have shown that although the rate 

at which medical problems are reported among OEF/

OIF veterans in the VA is fairly constant, the rate at 

which mental health problems are reported increases 

with time. 

The VA findings summarized in Table 20-1 demonstrate the broad range of mental health diagnoses 

to consider, including about as many cases of mood 

disorder and substance abuse or dependence as of 

PTSD. A similar ratio was observed in New York 

City in the wake of the September 11, 2001, attack 

on the World Trade Center.15 Hoge et al3

 noted a 

significant increase in major depression and generalized anxiety disorder, as well as in PTSD, among 

recently deployed soldiers and marines. Postdeployment mental health cannot be about just 

PTSD anymore.

TABLE 20-1 

PROVISIONAL MENTAL HEALTH DIAGNOSES

AMONG OEF/OIF VETERANS PRESENTING 

FOR VA MEDICAL CARE

Diagnosis Number

Posttraumatic stress disorder 67,525* 

Acute reaction to stress 4,070

Nondependent abuse of drugs† 54,415

Depressive disorder 45,155

Affective psychoses 25,399

Neurotic disorders‡ 35,605

Alcohol dependence 11,245

Drug dependence 5,062

*21% of total

†

Excessive tobacco use accounts for a large portion of those identified 

as involved in nondependent abuse of drugs.

‡

This category includes a number of anxiety disorders such as generalized anxiety disorder and panic disorder.

OEF: Operation Enduring Freedom

OIF: Operation Iraqi Freedom

VA: Department of Veterans Affairs
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Combat and Operational Behavioral Health

NEW PROGRAMS FOR COMBAT VETERANS AND THEIR FAMILIES

As noted above, Hoge and colleagues at WRAIR 

demonstrated that the stigma associated with reporting postdeployment mental health problems may be 

the single greatest obstacle to accessing care.3

 Their 

2004 study reported findings from over 3,600 active 

duty soldiers and marines 3 to 4 months after their return from service in Afghanistan or Iraq. For example, 

they found that when asked whether they had concerns about their decision to receive mental healthcare, 

65% of these combat veterans were concerned that “I 

would be seen as weak,” 63% were concerned that “my 

leadership might treat me differently,” and 59% were 

concerned that “members of my unit might have less 

confidence in me.”3

The Joint Conference on Postdeployment Mental 

Health

Hoge and colleagues’ 2004 findings3 and strong 

interagency desire to optimize mental healthcare 

across the DoD/VA continuum inspired plans for a 

joint DoD/VA conference on postdeployment mental 

health. Held in Alexandria, Virginia, on March 8–10, 

2005, this conference was cochaired by Colonel Elspeth 

Ritchie, psychiatry consultant to the Army surgeon 

general, and Harold Kudler, MD, then cochair of the 

VA Under Secretary for Health’s Special Committee 

on PTSD. Among the over 50 participants were the 

assistant secretary of defense for health affairs; the 

deputy secretary for veterans affairs; the surgeons 

general of the Army, Navy, and Air Force; mental 

health experts from across the DoD and VA; other representatives of Army, Navy, Marine Corps, Air Force, 

Coast Guard, National Guard, and reserve forces; 

and leading researchers and health systems planners 

from across the DoD and VA. Given the composition 

of its membership and the agenda set, the meeting 

might have been expected to result in the definition 

of a medical model for assessing and treating PTSD, 

depression, substance abuse, and other mental health 

diagnoses. Instead, the participants concluded this 

historic conference by defining a public health model 

for deployment mental health that has set the tone for 

DoD/VA efforts ever since. 

The Public Health Model for Deployment Mental 

Health

The public health model sprang from the observation that most warfighters or veterans will not develop 

a mental illness, but that all warfighters or veterans 

and their families face important readjustment issues. 

These problems in living may be painful and at times 

disabling, but they are, nonetheless, normal responses 

to extreme stress rather than medical illnesses. Within 

the public health model, the focus is less on making 

diagnoses than on helping individuals and families 

retain or regain a healthy balance despite the multiple 

stressors associated with the deployment cycle. This 

approach incorporates the recovery model and other 

principles of the President’s New Freedom Commission on Mental Health,16 including the importance of 

fostering resiliency and independence. 

The term “recovery” is generally associated with the 

reduction or remission of symptoms and signs specific 

to a given disease. Recovery also refers to the process 

by which people become progressively more able to 

live, learn, work, love, and fulfill a valuable and satisfying role within their families and their communities 

despite an ongoing medical problem. Thus, “recovery” 

may not be the same thing as “cure.” As Parsons has 

shown,17 disease is a biomedical process, but illness 

is largely a social process in which a person who has 

a disease accepts the sick role and its implicit and explicit limitations. Not everyone who has a disease lives 

within the sick role; there is a difference between having a significant problem (even a significant medical 

problem) and being disabled. Even when the signs and 

symptoms of disease are clearly disabling, recovery 

can be understood as the ability to live a fulfilling and 

productive life despite medical limitations. Recovery 

might also be understood as a life in which hope succeeds in sustaining the individual and the family even 

when medical efforts have failed.

“Resilience” refers to the qualities of an individual, 

a family, or a community that enable it to cope and 

rebound despite extreme stress. Resilience likely has 

psychological, biological, and social underpinnings 

with a different configuration in every person, family, 

and society. Resilient people retain or regain a sense of 

mastery, competence, and hope in response to adversity. Jerome Frank, who served as an Army psychiatrist during World War II, and went on to study how 

people cope with and recover from illness and stress 

in diverse cultures,18 suggested that the restoration 

of morale was the common element in all successful 

forms of therapy.19

A public health model, while medically informed, 

is quite different than a traditional medical model. It 

coordinates the efforts of traditional medical programs 

but also extends into nonmedical settings. In a public 

health model based on recovery and resilience, the 

question is less “How do you feel?” than “How are 

you doing?” New combat veterans usually experience 
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

the first question as insensitive and difficult to answer. 

The latter question places the focus on function and 

readjustment and will, therefore, engage the veteran 

in a more useful conversation.20

Hoge et als’ findings,3 and the VA utilization statistics provided above, demonstrate that it is not sufficient 

to announce that effective mental health treatment 

exists within the DoD and VA. Although many will 

appreciate the offer of care, only a minority will access 

it; the stigma associated with needing help is simply 

too powerful. The public health model circumvents 

the stigma associated with traditional mental health 

services by reaching directly into primary care settings 

and into the larger community. The primary care clinic 

is the de facto mental health system for a significant 

portion of the population. In times of trouble, people 

trust their primary care providers more than any other 

authority in their community.21 Web sites and public 

service announcements help get the word out, but for 

the message to take hold and access to be maximized, 

it is necessary to partner with allies in the greater 

community. Among the most important of these is 

the veteran’s family, because family members often 

decide when and where the veteran will seek help. Furthermore, resilient, supportive families significantly 

increase the resiliency of their members.22,23

Other allies include DoD and VA chaplains, DoD’s 

family support programs for active and reserve component members, military medical boards, VBA, local 

health providers (including TRICARE providers), 

community mental health centers, public schools, 

local colleges (where many new combat veterans 

study), employers, local congregations, military unit 

associations, and veterans’ service organizations. Military OneSource, a telephone and Web-based service 

available free of charge to service members and their 

families through a contract with DoD,24 is a confidential and highly accessible outreach tool, but its service 

is most effective in coordination with the full range of 

public health resources available to veterans. 

The highly successful Vet Center program was 

founded on public health principles and serves as a 

model for current efforts. RCS was specifically engineered to meet the needs of those Vietnam veterans 

who had reservations about seeking care at VA medical centers. RCS Vet Centers are neither hospitals nor 

mental health centers; they are community-based 

“storefront” operations. As its name clearly implies, 

RCS is about readjustment, not about mental illness. 

RCS freely involves family members and encourages 

them to share their concerns and express their own 

needs. RCS has proven effective in overcoming the 

stigma that kept many combat veterans from presenting to military or VA medical centers. Current public 

health efforts to reach a new generation of combat 

veterans and their families build upon the success of 

the RCS model. 

Because the needs of OEF/OIF veterans and their 

families change over time (as does their access to different services), the public health approach requires a 

progressively engaging, phase-appropriate integration 

of services across the DoD/VA continuum. This program must (a) be driven by the needs of the veterans 

and their families rather than by existing organizational structures and processes; (b) meet prospective 

users where they live rather than wait for them to find 

their way to the right mix of services; and (c) better 

articulate the transition between DoD and VA. Shared 

computerized medical record systems, and standardized, longitudinal follow-up of mutually agreed upon 

baseline assessment measures may in time significantly strengthen the DoD/VA continuum of care. There is 

also an opportunity to optimize the interplay between 

the DoD medical board and the VBA service connection processes to accelerate the rate at which new 

veterans and their families can access the constellation 

of services designed to meet their needs.

Post-Deployment Health Re-Assessment: A New 

Level of Service Integration

In recognition that physical health, mental health, or 

other readjustment problems may not be immediately 

apparent or may take time to develop,3

 DoD developed 

the PDHRA as a follow-up to the postdeployment 

health assessment performed at the time of return from 

a contingency operation. PDHRA is performed 3 to 6 

months postdeployment to ensure timely outreach, 

education, training, screening, assessment, triage, 

treatment, and follow-up. This intervention incorporates a nonpathologizing public health approach 

framed within a global health initiative. 

Screening utilizes a standardized tool, the DD 

Form 2900. Service members fill out the self-report 

section of the form within the context of a special 

education and training session, focused on common 

deployment-related health concerns, that provides 

information on the range of responses and benefits 

available to meet their needs. Each service member’s 

responses are reviewed with a healthcare provider to 

clarify issues, gather any needed clinical information, 

and ensure appropriate connection to services ranging 

from community-based support and preclinical counseling to referral for treatment in primary care, mental 

healthcare, other specialty care, or rehabilitative care 

as appropriate. 

PDHRA is medically informed to effectively identify 

clinical problems and facilitate access to care, but, in 
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Combat and Operational Behavioral Health

line with the public health model, the intervention 

emphasizes readjustment opportunities rather than 

pathology and disability. Vet Center and VA Seamless 

Transition staff and veterans’ benefits counselors are 

on hand at PDHRA events to assist service members 

entering veteran status. To improve access to mental 

healthcare, military and VA medical systems are both 

in the process of increasing its integration into primary 

care settings. Efforts are underway to allow sharing of 

DD Form 2900 findings between DoD and VA clinicians to assure continuity of care across systems. 

Battlemind Training

Hoge and colleagues3 demonstrated that the stigma 

surrounding postdeployment readjustment stress is a 

significant barrier to new combat veterans receiving 

appropriate care. To get around this stigma, Hoge and 

his team at WRAIR developed and tested a new outreach approach to engage OEF/OIF combat veterans: 

Battlemind training.25 Battlemind training has now 

been incorporated into the PDHRA intervention for 

the Army. (The US Marine Corps’ Warrior Transition 

Program26 addresses similar issues but is adapted to 

meet the unique needs of marines.) 

“Battlemind” is an acronym for:

 Buddies vs withdrawal

 Accountability vs control

 Targeted vs inappropriate aggression

 Tactical awareness vs hypervigilance

 Lethally armed vs unarmed

 Emotional control vs anger or detachment

 Mission and operational security vs secretiveness

 Individual responsibility vs guilt

 Nondefensive (combat) driving vs aggressive 

driving

 Discipline and ordering vs conflict

Each element of Battlemind training speaks to an 

important aspect of postdeployment readjustment, 

and each is illustrated and explained in the video 

presentation (viewable at https://www.battlemind.

army.mil/) that forms the centerpiece of training. 

Consonant with the public health model, Battlemind 

emphasizes resiliency rather than pathology, and engages service members through training rather than 

direct offers of treatment. Further interventions up 

to and including appropriate clinical assessment and 

treatment are more likely to be accepted if this initial 

outreach is accepted. 

Battlemind training is designed to be highly acceptable to new combat veterans. Its key message is that 

combat skills and battle mindset sustained the warfighter’s survival in the war zone. Battlemind is defined as the service member’s inner strength to face fear 

and adversity in combat with courage. If, on returning home, service members find that they still “sleep 

with one eye open,” are constantly on alert for signs of 

danger, and respond reflexively with aggression, this is 

evidence that they have adapted to the war zone. This 

explanation is quite different than telling new combat 

veterans that they may be expressing symptoms of a 

mental disorder such as PTSD. The clear implication 

is a positive one: if you were able to adapt to life in a 

war zone, you should be able to adapt again to life at 

home. In short, Battlemind training tells new combat 

veterans that their responses are the normal responses 

of good warfighters, but it also stresses that Battlemind 

may be hazardous to social and behavioral health on 

the home front if it is not transitioned: in other words, 

“don’t try this at home.” Battlemind training has been 

expanded to include spouse Battlemind training for 

both predeployment and postdeployment use. During 

2006, qualified instructors from WRAIR trained all Vet 

Center staff members in Battlemind principles.

Extending and Strengthening the Continuum of 

Care

As this review demonstrates, DoD and VA have 

worked steadily since the start of operations in Afghanistan and Iraq to mesh the gears of their respective agencies through the development of joint clinical 

practice guidelines, the Joint VA/DoD Federal Recovery Coordination Program, PDHRA, and Battlemind 

training to extend and enhance the continuum of care 

for OEF/OIF veterans and their families. These steps 

can be understood as practical applications of a public 

health model particularly suited to this newest generation of combat veterans. 

In 2005 the VA implemented a new program founded on these same principles, which was subsequently 

named Services for Returning Veterans-Mental Health 

(SeRV-MH). Rather than diagnosing specific disorders 

or limiting services to highly specialized interventions 

for PTSD, depression, or substance abuse, the goals of 

SeRV-MH are engagement, health promotion, recovery, and rehabilitation. Triage to primary care, general 

mental health services, and subspecialty services are 

available through SeRV-MH teams. SeRV-MH teams 

actively engage other VHA, VBA, and Vet Center 

programs; DoD active duty and reserve components; 

and other federal, state, and community agencies and 

programs in support of new combat veterans and their 

families. 

Although outreach was initially identified as a core 
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

SeRV-MH function, that role is, as noted above, the purview of Vet Centers, so SeRV-MH outreach is carried 

out in collaboration with Vet Center initiatives. SeRVMH teams are distinguished by their unique “in-reach” 

function, which includes services in primary care settings designed to enhance access to behavioral health 

services while reducing the stigma that veterans and 

their families often associate with formal mental health 

settings. SeRV-MH staff members also support facility 

polytrauma services, including those for veterans with 

traumatic brain injury. Service delivery innovations to 

meet the needs of returning veterans who go to work 

or school include the establishment of weekend and 

evening SeRV-MH clinic hours. 

SeRV-MH teams are agents of change within the 

various programs, promoting a view of mental health 

as an essential part of overall health and function. They 

help other VA clinical, administrative, and support 

staff to become aware of the special characteristics of 

OEF/OIF veterans and their families and develop new 

methods of intervention. They embody and disseminate the public health model. More than 80 SeRV-MH 

teams are now distributed across the nation (at least 

one per state), and nationally coordinated training 

(developed by a multidisciplinary DoD/VA team) is 

being rolled out. This training includes information on 

the Army Battlemind approach and education on topics not addressed in more traditional curricula on war 

stress disorders, such as improving closeness among 

family members and addressing traumatic grief. 

The VA has also launched a Mental Illness Research, 

Education, and Clinic Center (MIRECC) dedicated to 

postdeployment mental health.27 MIRECCs were established by Congress in 1997 as translational research 

centers. Ten MIRECCs exist nationwide and each is 

dedicated to a specific area of mental illness, such as 

schizophrenia, substance abuse, or dementia. Their 

stated mission is 

to generate new knowledge about the causes and 

treatments of mental disorders, apply new findings 

to model clinical programs, and widely disseminate 

new findings through education to improve the quality of veterans’ lives and their daily functioning in 

their recovering from mental illness.28

The postdeployment MIRECC works with clinicians 

and researchers across the DoD/VA continuum to 

identify, develop, and disseminate best clinical practices in the service of new combat veterans and their 

families. Some of this work stems from MIRECC laboratory, health services, and epidemiological research, 

while other efforts apply and test new clinical models 

and educate other health workers, the general public, 

and OEF/OIF veterans and their families. 

BEYOND THE DEPARTMENT OF DEFENSE/VETERANS AFFAIRS CONTINUUM

Ideally, the postdeployment readjustment and mental health problems of OEF/OIF veterans would be 

identified and addressed somewhere within the DoD/

VA continuum of care, but this may not be a realistic 

expectation. Hoge et al29 conducted a population-based 

descriptive study of all soldiers and marines who returned from deployment to OEF (n = 16,318), OIF (n = 

222,620), and other locations (n = 64,967) between May 

1, 2003, and April 30, 2004. They found that the prevalence of reporting a mental health problemwas 19.1% 

among service members returning from Iraq, 11.3% 

after returning from Afghanistan, and 8.5% (close to 

the base rate in the military) after returningfrom other 

locations (P < 0.001). Although 35% ofall OIF veterans 

accessed mental health services at least once within a 

yearafter their return home, 60% of those who screened 

positive for PTSD, major depression, or generalized 

anxiety (substance abuse was not addressed in this 

study) failed to present for any mental health service. 

These DoD findings closely parallel those in the VA 

that (as noted above) show that, as of February 2008, 

only 39% of all OEF/OIF veterans eligible for VA care 

have come to the VA for health services. Where are the 

other 61% of OEF/OIF veterans, and what are their 

mental health needs?

Another parallel exists between this information 

and the findings of the National Vietnam Veterans Readjustment Study,30 which found that only 20% of Vietnam veterans who fulfilled diagnostic criteria for PTSD 

at the time of the study (conducted in the late 1980s) 

had ever gone to the VA for mental healthcare.30(p228)

The same study found that 62% of all Vietnam veterans 

with PTSD had sought mental healthcare somewhere 

at some point in time. In other words, among Vietnam 

veterans with PTSD at the time of the study who ever 

sought mental healthcare, only 32% came to the VA for 

that care, while 68% went elsewhere for care. 

These findings suggest that a “silent majority” of 

OEF/OIF veterans with postdeployment readjustment 

or mental health issues may not seek help within the 

DoD/VA continuum of care. Stigma may be the key 

reason for this. But if a silent majority does exist, several important questions face DoD and VA planners 

and clinicians: 

• Who among these veterans should be 

reached?

• What are the best ways to reach them?
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Combat and Operational Behavioral Health

• At what point should they be reached?

• What interventions would be most appropriate once they have been reached?

• What about their families?

Work with the families is particularly important 

because the level of postdeployment social support 

received by combat veterans strongly predicts their 

resilience.22,23 In addition, if new combat veterans are 

going to get needed help, family members will likely 

be instrumental in their getting it. Finally, families have 

needs of their own that, if left unmet, could have serious consequences for the families and their communities. To reach new combat veterans and their families, 

it is necessary for the DoD and VA to look beyond their 

own continuum of care towards partnerships at the 

state and community levels.

State and Community Partnerships

The DoD and VA realize a number of advantages 

in partnering at the state and community levels. Such 

partnerships enhance access for service members, 

veterans, and family members who are concerned 

about seeking help within the DoD/VA continuum. 

Partnerships may also enhance the quality of services 

new combat veterans and their family members receive 

in the community through joint training and improved 

interagency cooperation. 

Because National Guard programs are organized 

at the state level, it makes sense for DoD and VA to 

develop state-level partnerships. Furthermore, each 

state has its own veterans’ service program. Veterans’ 

service officers in each county or region of the state 

work with veterans and their families to connect 

them with federal, state, and local programs that significantly improve their access to care, benefits, and 

reliable information. Finally, partnerships among the 

DoD, VA, states, and local communities help build new 

systems of interagency communication and coordination that may serve well at times of local or regional 

disaster. A number of DoD, VA, state, and community 

partnerships already exist in areas such as upstate New 

York, Washington state, Ohio, North Carolina, Virginia, 

Alabama, Vermont, and Rhode Island. Because each 

state has a different array of military bases, reserve 

units, VA facilities, and veteran populations, each faces 

unique challenges and opportunities.

One recent example of the DoD, VA, state, and 

community partnership was introduced on February 

12, 2007, when the VA announced a national roll out 

of a partnership with state veterans’ service officers 

through the National Association of State Directors 

of Veterans Affairs. This program links VA staff based 

at 10 DoD MTFs around the country with state veterans’ service officers in all 50 states. The program 

helps identify injured military members who are being 

transferred to VA care so that state veterans’ officers 

can more efficiently identify, locate, and link them and 

their family members to appropriate state benefits and 

services.31

Partnerships can and should extend well beyond the 

traditional scope of mental health and substance abuse 

services to include local primary care providers, pediatricians, ministers and congregations, teachers and 

school guidance counselors, campus-based veterans’ 

benefits specialists, veterans’ service organizations, 

mental health associations and advocacy organizations, employers and supervisors, law enforcement 

agents, judges, and others in order to make diverse 

members of the community more aware of the problems faced by OEF/OIF veterans and their families 

and of the resources available to assist them. 

These partnerships often begin with a state-level 

summit meeting of potential partners including 

state-based DoD and VA elements. These conferences 

generally open with a presentation of the “boots on 

the ground” experiences of new combat veterans and 

the deployment cycle experiences of their families. The 

presence of top leadership, including the governor, 

the state secretary for health and human services, the 

adjutant general of the state National Guard, senior 

leadership from state-based DoD military programs 

and medical facilities, and VA network leadership, 

provides a strong and positive message to participants 

about the importance of the effort and the will of each 

respective partner to pursue it. 

Representatives to the summit meeting exchange 

key information about their respective agencies’ assets 

and goals to identify strategic partnerships in service 

for new combat veterans and their families. Attendees 

work to articulate an integrated continuum of care that 

emphasizes access, quality, effectiveness, efficiency, 

and compassion. Services are centered on service 

members or veterans and their families. Principles of 

resilience, prevention, and recovery are emphasized. 

Attendees agree to work together to optimize access 

to information, support, and, when necessary, clinical 

services across systems as part of a balanced public 

health approach. The product envisioned is a network 

of informational, supportive, clinical, and administrative services through which citizens of the state will 

have ready access to postdeployment readjustment 

assistance. The DoD, VA, state, and community partnership may begin with a single high-profile meeting 

as described above, but if the process is to be successful, 

it must be sustained. This calls for ongoing meetings 

of working subgroups, continued support within 
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

each partnering entity, and a clear and practical joint 

plan with scheduled deliverables and clear lines of 

responsibility. 

Key Elements Replicable in Every State

Some states are home to major military bases embedded within strong military-friendly communities. 

In such settings, postdeployment issues are often well 

recognized by local leaders, health professionals, teachers, guidance counselors, school principals, and local 

clergy. Many community support mechanisms may 

already be in place. Other states have few, if any, major 

bases, but have large numbers of reserve or National 

Guard members. Because these citizen soldiers tend 

to be scattered across communities (and relatively 

invisible within them), local leaders, health professionals, school personnel, and religious leaders may 

be less aware of deployment-related issues and less 

knowledgeable about how to access resources once a 

need is identified. Nonetheless, there are certain core 

elements of the DoD, VA, state, and community partnerships that can be successfully replicated in every 

community and state.

The first element is effective outreach. One basic 

mechanism is development of a governor’s letter to 

new combat veterans and their families. Because each 

state director of veterans’ services receives a list of 

the names and mailing addresses of every OEF/OIF 

veteran living within the state, it is possible for the governor’s office to reach out to every affected household. 

The North Carolina Governor’s Focus on Returning 

Combat Veterans and Their Families recommended in 

its final report32 that such a letter be sent to all service 

members and their families, thanking them on behalf 

of the entire state. The letter also invites recipients to 

make use of local resources as they readjust. In North 

Carolina, the letter provides a toll-free telephone number that combat veterans or family members can call for 

information and guidance to appropriate resources. As 

a key step toward enhancing resilience, the governor 

can conclude the letter by recognizing the strength, 

skills, and willingness to sacrifice demonstrated by 

veterans and their families. 

The toll-free number used in North Carolina is an 

application of a preexisting “care line” system established by the state Department of Health and Human 

Services. It is staffed by information-and-referral 

specialists trained about a wide variety of human 

service programs across the state.33 Care line services 

are provided in English and in Spanish and as a TTY 

(text telephone) service for the hearing-impaired (an 

important consideration among combat veterans). 

Until recently, these specialists did not routinely 

inquire whether a caller was a service member, a veteran, or someone calling about a service member or 

a veteran or in relation to postdeployment issues. 

These specialists have now undergone training on 

deployment mental health issues and have begun applying a simple algorithm when fielding calls. They 

ask about the caller’s service in Iraq or Afghanistan, 

military branch, current military status (active duty 

or reserve component), date separated from service, 

date of return from last deployment, and zip code or 

county of residence. 

With this information in hand, a range of services 

can quickly be identified and located in proximity 

to the caller’s residence. The list of potential access 

points resides on an electronic database of over 10,000 

agencies and programs across the state. The referral 

specialist can identify the caller’s local Vet Center 

(and its GWOT outreach worker if one exists); the 

county veterans’ services officer; the seamless transition case manager at the local VA medical center; 

any service-appropriate family program (such as the 

Guard Family Readiness Group); and the nearest regional VBA. The specialist can also put the caller in 

touch with Military OneSource or TRICARE services 

as appropriate to the caller’s needs. This information 

can also be obtained at the care line Web site (http://

www.nccareline.org). 

Joint training efforts are required to build strong 

bridges between the DoD, VA, state, and community 

programs. These should include leaders and clinicians working in local mental health, primary care, 

and family support programs, as well as professional 

organizations and other state and community groups. 

Area Health Education Centers (AHECs), developed 

by Congress in 1971 to recruit, train, and retain a health 

professions workforce committed to underserved 

populations,34 exist in almost every state. AHECs can 

play an important role in disseminating best practices 

and developing a common language and approach 

among federal, state, and community systems. 

One strategy that can be employed with relative 

ease is to develop an AHEC educational program 

based on Battlemind training. Trainers can be recruited 

from local DoD and VA sites. Battlemind training 

videos and supporting materials are available in the 

public domain. Although Battlemind is an Army program and the Warrior Transition Program is a Marine 

Corps program, both incorporate principles that speak 

to universal issues of the deployment cycle and can 

be adapted to different audiences while still respecting distinct cultural differences among the military 

branches. 

Local PDHRA events also offer important opportunities for the DoD, VA, state, and community cooperation. DoD and VA staffs routinely meet with local 

military units (and often with their family members) 
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Combat and Operational Behavioral Health

during PDHRA. State and community representatives 

could be invited to attend to help reinforce transition 

back to the community and inform service members 

and their families about readjustment resources such 

as medical, vocational, and benefits programs. At the 

same time, participating state and community representatives have the opportunity to learn more about 

the challenges faced by new combat veterans and their 

families, which can then inform further efforts on their 

behalf. Partnerships should coordinate DoD, VA, state, 

and community efforts with those of local providers 

who contract with TRICARE and Military OneSource 

to assure full and ready access to well-trained clinicians 

for service members, new veterans, and their families. 

AHECs can disseminate needed clinical training and 

can also provide information about working with TRICARE (which could lead to more providers choosing 

to become TRICARE providers).

Many service members, veterans, and family members prefer to bring readjustment issues to their chaplain or local religious leader rather than to a medical 

provider. DoD, VA, state, and community partnerships 

offer a unique opportunity for interchange between 

military and VA chaplains and local clergy and their 

faith communities. These partnerships can substantially increase social support for returning combat 

veterans and their families. Clinical pastoral education programs are ideally suited to develop outreach 

and educational activities that promote readjustment, 

resilience, and recovery. Again, Army Battlemind training and the Marine Corps Warrior Transition Program 

can provide core content for instruction that can be 

adapted for specific faith communities. The strategies 

and tactics presented here are not meant to serve as 

an exhaustive list but rather as a jumping-off point for 

new ideas. It is essential that each community explore 

and develop partnerships specific to its own unique 

needs and assets. 

SUMMARY

The VA has long-standing readjustment services 

stemming from Vietnam-era initiatives such as the 

Vet Center program; however, new programs have 

arisen in response to studies finding these efforts 

inadequate. The DoD and VA have established joint 

efforts built on a public health model, including partnerships with state and community resources. These 

partnerships are designed to enhance support and 

outreach, improve referral systems, reduce stigma, 

and promote better health outcomes for new combat 

veterans and their families. The goals of all these 

programs are to provide a seamless continuum of 

care that will support increased resilience, decreased 

military attrition, and decreased disability, as well as 

increased satisfaction among consumers and providers. Experience to date indicates that these ambitious 

goals are attainable. The ultimate goal is to transform 

the postdeployment health system: there should be 

no wrong door to which OEF/OIF veterans or their 

families can come for help. The DoD and VA have 

made significant progress in providing seamless 

healthcare coverage to transitioning veterans and 

their families since the start of military operations in 

Afghanistan and Iraq. The public health model and 

the DoD, VA, state, and community partnerships help 

mark the path for future progress. 

Acknowledgment

The authors gratefully acknowledge the careful review and suggestions made by Dr Kristy Straits-Tröster 

of the VA Mid-Atlantic Health Care Network’s Mental Illness Research, Education, and Clinical Center in 

the course of developing this chapter.

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