1 

Stephen C Hunt MD MPH

Lucile Burgo MD 

Director/Co-Director, Post-Deployment Integrated Care Initiative (PDICI) 

HSR&D CyberSeminar March 5, 2013 

Transforming Post-Deployment Care

Transforming Pain Care

Transforming Health Care

Researchers as Team Mates
Poll Question #1

• What is your primary role in VA? (128 character limit for the 

question)

– student, trainee, or fellow (60 character limit for each answer choice)

– clinician

– researcher

– manager or policy-maker

– Other

Up to five answer options. Can be “select one” or “select all that apply”
Poll Question #1

• Do you have a role in PACT? (128 character limit for the 

question)

– Teamlet member(60 character limit for each answer choice)

– Expanded PACT member

– manager or policy-maker

– Other

Up to five answer options. Can be “select one” or “select all that apply”
 

HSR&D

Health Services Research and Development

...research that underscores all aspects of VA healthcare: patient care, 

care delivery, health outcomes, cost, and quality as well as critical 

issues for Veterans returning home from Iraq and Afghanistan with 

conditions that may require care over their lifetimes. 

Within VA HSR&D, researchers focus on identifying and evaluating 

innovative strategies that lead to accessible, high quality, costeffective care for Veterans and the nation
Transforming Post-Deployment Care
We knew that the health risks of 

combat were many...
• Musculoskeletal 57.5%

• Mental disorders 53.6%

• Symptoms/signs 52.8%

• Nervous system (hearing) 45.8%

• GI (dental) 36.2%

• Endocrine/Nutrition 33.3%

• Injury/Poisoning 29.0%

• Respiratory 26.5%

VHA Office of Public Health and Environmental Hazards 

Released: January 2013

7 

1,557,026 of the 2.5 million deployed, are separated and 

eligible for VA 

56 % (866,182) have been seen in VA between FY02 and 

October 1, 2012

 

...and that the health impacts were prevalent...
Overall prevalence:

Pain 81.5%

TBI 68.2%

PTSD 66.8%

PTSD

TBI/Pain

P3 Multi-symptom 

Disorder 

Lew, Otis, Tun, Kerns, Clark, & Cifu, JRR&D; 2009

Sample = 340 OEF/OIF outpatients at Boston VA

42.1% 

5.3%

2. %

16.5%

10.3%

12.6%

6.8%

CLARK- 2009

...and complex...
9 
 

We had learned a great deal from our 

experiences with Veterans from earlier 

conflicts... 
Rate the degree to which you 

believe 

“Persian Gulf Illness” is:

P

e

r

c

e

n

t 

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.
P

e

r

c

e

n

t 

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.
13
 We knew that there were 

physical 

risks and impacts of combat...

 

injury noise 

temperature sleep deprivation 

diet austere conditions 

toxic agents infectious agents

 multiple immunizations blast wave/head injury
 We knew that there were 

psychological 

risks and impacts of combat...

 

 anticipation of combat

 combat trauma 

 non-combat trauma 

 separation from family/home 

 deprivation
 We knew that there were 

psychosocial 

risks and impacts of combat...

 

 Marital/parenting issues

 Social functioning

 Occupational/financial concerns

 Risk of re-deployment

 Spiritual / existential
Primary Care-Mental Health Integration

(Primary Care Mental Health Integration Initiative 2007)

PCP MH 

Provider Veteran
PDICI (Post-Deployment Integrated Care Initiative 2008)

Physical Psychological 

Veteran

Psychosocial 
Integrated Post-Combat Care

PDICI (Post-Deployment Integrated Care Initiative 2008)

Primary Care 

Provider Mental Health

Provider Veteran

Social Worker 
MAJORITY OF OEF/OIF VETERANS RECEIVE THEIR INITIAL 

PRIMARY CARE CLINICAL EVALUATION WITH THE...

 OEF/OIF Post Deployment Clinic 54%

 OEF/OIF Primary Care Cohort 34%

General Primary Care Clinic(s) 12%

QuERI: Mittman, Wyte, MacGregor 
AS PART OF THE INITIAL CLINICAL EVALUATION 

PROCESS FOR OEF/OIF VETERANS...

48%

...a social worker/case 

manager typically 

conducts a separate 

evaluation

...a mental health 

specialist typically 

conducts a separate 

evaluation and/or combat 

stress assessment

87%

QuERI: Mittman, Wyte, MacGregor 



 

...and were learning in real time...
1st Quarter FY 2002 through 4nd Quarter FY 2011

Office of Public Health and Environmental Hazards December 2011

26
 

Am J Psychiatry 159:12, December 2002
 What are the stressors of war?

 Psychosocial

 

 Marital/parenting issues

 Social functioning

 Occupational/financial concerns

 Risk of re-deployment

 Spiritual / existential
 
 
 



35

Implementation of the Pain Directive

•

1. Education of Veterans

2. Education and training of Teams

3. Establish primary care Pain Champion, pain resource providers, 

pain teams (pain resource nurse, pain resource pharmacist, pain 

psychologist)

4. Development of non-pharmacological modalities

5. Strengthen capacity for connecting the specialists with the 

PACTs: e consult, ECHO/SCAN, telephone consult services, 

Office Communicator

6. Instituting safe opioid prescribing (universal precautions, opioid

surveillance)

7. Metrics/dashboards to monitor and maintain pain care

• 

Transforming Veterans Pain Care
36

Implementation of the Pain Directive

•

1. Education of Veterans

2. Education and training of Teams

3. Establish primary care Pain Champion, pain resource providers, 

pain teams (pain resource nurse, pain resource pharmacist, pain 

psychologist)

4. Development of non-pharmacological modalities

5. Strengthen capacity for connecting the specialists with the 

PACTs: e consult, ECHO/SCAN, telephone consult services, 

Office Communicator

6. Instituting safe opioid prescribing (universal precautions, opioid

surveillance)

7. Metrics/dashboards to monitor and maintain pain care

• 

Transforming Veterans Pain Care
37

Implementation of the Pain Directive

•

1. Education of Veterans

2. Education and training of Teams

3. Establish primary care Pain Champion, pain resource providers, 

pain teams (pain resource nurse, pain resource pharmacist, pain 

psychologist, BH support/HBC)

4. Development of non-pharmacological modalities

5. Strengthen capacity for connecting the specialists with the 

PACTs: e consult, ECHO/SCAN, telephone consult services, 

telehealth, Office Communicator

6. Instituting safe opioid prescribing (universal precautions, opioid

surveillance)

7. Metrics/dashboards to monitor and maintain pain care

• 

Transforming Veterans Pain Care
38

Implementation of the Pain Directive

•

1. Education of Veterans

2. Education and training of Teams

3. Establish primary care Pain Champion, pain resource providers, 

pain teams (pain resource nurse, pain resource pharmacist, pain 

psychologist)

4. Development of non-pharmacological modalities

5. Strengthen capacity for connecting the specialists with the 

PACTs: e consult, ECHO/SCAN, telephone consult services, 

Office Communicator

6. Instituting safe opioid prescribing (universal precautions, opioid

surveillance)

7. Metrics/dashboards to monitor and maintain pain care

• 

Transforming Veterans Pain Care
The Old Paradigm: Veteran needs specialist

Specialty

Provider 

PCP

Consult sent to 

Specialty Clinic

Specialty consult 

disposition/plan 

recorded in note
The Old Paradigm: Veteran needs specialist

Specialty

Provider 

PCP

Consult sent to 

Specialty Clinic

Specialty consult 

disposition/plan 

recorded in note
PACT

teamlet

The Pain Specialist and the Expanded PACT 

Team

Specialty

Provider What level of 

specialty input does 

the Veteran need and 

how do we best 

connect, collaborate 

and coordinate?
PACT

teamlet

The Specialist and the Expanded PACT Team

Specialty

Provider 

Level 3:

Veteran and PACT team 

need input from specialist 

but not necessarily a 

Veteran visit with the 

specialist

•f/u on Pain

 assessment

•Pain/PTSD/other

 co-morbidity 

Team function:

•Documentation on

 over-arching treatment

 plan

•Non-visit consult note

•Specialist has direct

 communication with team:

•Tele-conference

•SCAN

•Office Communicator

 day of visit
PACT

teamlet

The Specialist and the Expanded PACT Team

Specialty

Provider 

Level 2:

Veteran needs specialized 

care that is best delivered in 

a more collaborative setting

•Pain with/without PTSD

•rehab/pain issues

•Health recovery rehab Plan

•CBT, brief behavioral 

interventions 

Team function:

•Documentation on

 over-arching treatment

 plan

•Specialist has direct

 communication with PCP:

•Telephone call

•Secure e mail/text

•OC on day of visit 

•Specialist attends team

 meeting

•Coordination of care

 through specialty clinic

 care manager and PACT

 RN Care Manager
PACT

teamlet

The Specialist and the Expanded PACT Team

Specialty

Provider 

Level 1:

Veteran needs highly 

specialized cares that

will be delivered in

the specialty setting:

•Moderate/severe 

chronic pain

•Need for interventional 

pain care

•High/moderate levels

of general or specialized 

rehab, cognitive rehab,

OT, speech tx

Team function:

•Contact between specialist

 and PCP

•Documentation on

 over-arching treatment

 plan

•Coordination of care

 through specialty clinic

 care manager and PACT

 RN Care Manager
FAMILY

C LINICAL

A SSOCIATE

PC 

P ROVIDER

CLERK

RN C ARE

M ANAGER

45
Stepped Pain Care

STEP

1 

STEP

2 

STEP

3 

Tertiary Interdisciplinary Pain Centers

Advanced diagnostics & interventions

Commission on Accreditation of Rehabilitation 

Facilities accredited pain rehabilitation

Integrated chronic pain and Substance Use 

Disorder treatment

Patient Aligned Care Team (PACT)

Routine screening for presence & intensity of pain

Comprehensive pain assessment

Management of common acute and chronic pain conditions

Mental Health-Primary Care Integration, Health Behavior 

Coordinators, Operation Enduring Freedom/Operation Iraqi 

Freedom, & Post-Deployment Teams

Expanded nurse care management 

Opioid Renewal Clinics; Pain Schools

Complexity

Treatment 

Refractory

Comorbidities

RISK

Secondary Consultation 

Pain Medicine

Rehabilitation Medicine

Behavioral Pain Management 

Multidisciplinary Pain Clinics

Substance Use Disorders Programs 

Mental Health Programs

 

46
47

Implementation of the Pain Directive

•

1. Education of Veterans

2. Education and training of Teams

3. Establish primary care Pain Champion, pain resource providers, 

pain teams (pain resource nurse, pain resource pharmacist, pain 

psychologist)

4. Development of non-pharmacological modalities

5. Strengthen capacity for connecting the specialists with the 

PACTs: e consult, ECHO/SCAN, telephone consult services, 

Office Communicator

6. Instituting safe opioid prescribing (universal precautions, opioid

surveillance)

7. Metrics/dashboards to monitor and maintain pain care

• 

Transforming Veterans Pain Care
48

Implementation of the Pain Directive

•

1. Education of Veterans

2. Education and training of Teams

3. Establish primary care Pain Champion, pain resource providers, 

pain teams (pain resource nurse, pain resource pharmacist, pain 

psychologist)

4. Development of non-pharmacological modalities

5. Strengthen capacity for connecting the specialists with the 

PACTs: e consult, ECHO/SCAN, telephone consult services, 

Office Communicator

6. Instituting safe opioid prescribing (universal precautions, opioid

surveillance)

7. Metrics/dashboards to monitor and maintain pain care

• 

Transforming Veterans Pain Care
49
Primary Care-Mental Health Integration

(Primary Care Mental Health Integration Initiative 2007)

PCP MH Veteran

We learned from other emerging care models...
51
52

Current Projects

•

1. Current HSR&D Projects and 

Initiatives (CREATE) 

2. Opioid Safety Initiative

3. Joint DoD/VA Pain Education 

Project (JIF JPEP) 

 2013:The Year of Pain Care

•

Transforming Veterans Pain Care
Transformation of Veterans Health Care

Veteran 

Centered, 

Team 

Based 

Power 

resides 

with the 

patient 

Care based on 

continuous 

healing 

relationships

Care is 

customized 

to individual’s 

needs and 

values

IOM 2001

Crossing the Quality Chasm
HSR&D Webinar

March 5, 2013 

QUESTIONS ? 

Stephen.hunt@va.gov

Lucille.burgo@va.gov

Transforming Post-Deployment Care 

Transforming Pain Care 

Transforming VA Health Care 

Researchers as Partners