Chiseled into the granite facade of VA’s Central 

Office are the words of Abraham Lincoln: “To 

care for him who shall have borne the battle 

and for his widow and orphan.” With the growing number of women serving in the military, 

including many who have experienced combat 

exposure, we revise those words in our hearts 

and minds to clarify our core VA mission: “To 

care for those who shall have borne the battle 

and for their families and loved ones.” What is 

our approach to accomplishing that mission? 

As VA and as a Nation, what is our approach 

to post-combat care?

Nearly 2.5 million U.S. troops have been deployed to the Iraq and Afghanistan theaters 

of conflict since 9/11. Many have had several deployments, often lasting more than a 

year, with downward trends in the intervals 

between deployments. The health concerns 

of those returning from deployment span a 

spectrum of co-occurring conditions, such as 

physical injury with chronic pain, diagnosable 

and sub-threshold mental health conditions, 

residuals of traumatic brain injuries, hearing 

loss, concerns about environmental exposures, 

and impairments in psychosocial functioning. 

A Systematic, Integrated Model

Building on lessons learned from the experiences 

and needs of Veterans from earlier conflicts, 

particularly those who served in the Vietnam 

War and Gulf War I, VA has transformed its 

approach to post-deployment care, moving to a 

much more systematic, structured, and integrated 

approach. The approach involves interdisciplinary teams conducting collaborative assessments 

of post-deployment physical, psychological, and 

psychosocial functioning through a primary care 

team–based, integrated model of care that ultimately has served as a model for VA’s Patient 

Aligned Care Teams (PACT). This model of care 

is Veteran-centered, beginning with an expression of appreciation for the Veteran’s service, 

an acknowledgment of the sacrifices that service 

has involved for the Veteran and his/her family, and attentiveness to the Veteran’s story. The 

Post-Deployment Integrated Care Initiative 

(PDICI) model, launched in 2008, was shaped by 

clinical and epidemiological research on similar 

populations with complex presentations and cooccurring health concerns that involve physical, 

psychological, and psychosocial impairments. 

Since then, PDICI has undergone continuous adaptation and improvement in response to ongoing clinical, epidemiological, and implementation 

research. A 2010 study revealed that, within 18 

months of PDICI implementation, 84 percent of 

VA Centers nationally had put in place integrated 

care platforms, teaming up medical providers, 

mental health providers, and social workers; the 

data also revealed enhancements in team function 

on the care teams. 

Recent Developments in 

Post-Deployment Care

Several developments in post-deployment care 

have emerged from the Iraq and Afghanistan 

conflicts, including the OEF/OIF/OND 

Program, the Polytrauma System of Care, 

the Primary Care/Mental Health Integration 

Program, enhanced mental health services, 

substance abuse and pain management services, and education/tertiary care support for 

FORUM

Translating research into quality health care for Veterans

Commentary

A Transformation in VA Post-Deployment Care

Stephen C. Hunt, M.D., M.P.H., VA Puget Sound Health Care System and 

Lucille Burgo-Black, M.D., Director and Co-Director, Post-Deployment Integrated 

Care Initiative, VA Connecticut Health Care System

 August 2013

Contents

Director’s Letter 2

The Value of Polytrauma 

Interdisciplinary Care 3

Barriers to Mental Health 

Treatment among Returning 

OEF/OIF Veterans 4

Mild Traumatic Brain Injury: 

Screening and Comorbidities 5

Peer Outreach for National 

Guard Soldiers—Assessing the 

BuddytoBuddy Program 6 

Accelerating Innovation and 

Translation through Strategic

Partnerships: CREATE and COIN 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, 

in conjunction with AcademyHealth. This and past issues 

of FORUM are available on the web at www.hsrd.research.

va.gov/publications/forum.
Veterans and their families through the Office 

of Public Health and the War Related Illness 

and Injury Study Centers as well as enhanced 

overall care integration through PDICI and 

PACT. VA has undertaken the critical task 

of hiring program and case managers to assist Veterans in navigating the VHA system, 

aligning services, developing integrated care 

plans, and supporting primary care–based 

team care. As these programs and systems 

have converged and more effectively collaborated, both in care delivery and research, what 

has evolved is an integrated system of postdeployment care that far exceeds anything in 

place for earlier cohorts of returning combat 

Veterans. VA no longer has “a bunch of good 

programs and resources for returning combat 

Veterans.” It has a comprehensive, systematic 

approach to post-deployment care with strong 

clinical, teaching, and research components.

The goals of integrated post-combat care include 

comprehensive evaluation of and treatment 

for post-deployment health concerns as well 

as optimal health recovery and reintegration of 

Veterans into civilian life. By partnering within 

VA and between VA and non-VA entities, we 

hope to mitigate as fully as possible—from both 

the individual clinical perspective and the population health perspective—the downstream health 

impacts of deployments on the lives and families 

of Veterans.

This approach is fully in line with the 2013 

IOM report titled Returning Home from Iraq and 

Afghanistan: Assessment of Readjustment Needs 

of Veterans, Service Members, and Their Families. 

The report concludes that, to ensure successful readjustment, service members and 

Veterans need an array of services to meet the 

challenges they face when returning home. 

Services include diagnostic, treatment, rehabilitation, education, outreach, and community 

support. Furthermore, the services must be 

effectively sequenced and integrated, guided 

by implementation research and validated by 

outcomes research.

As a corollary to the process of linking and 

integrating aspects of direct clinical care, the 

IOM report “. . . calls on the DoD and the 

VA to support comprehensive analysis of 

both departments’ data to answer questions 

about readjustment that are not addressed by 

peer-reviewed literature.” The IOM report 

reminds us of the critical importance of linking and integrating data across departments 

to allow researchers to analyze many of the 

key questions about readjustment. The transformation of VA’s post-deployment care has 

emerged from the classical partnership of the 

three Ps: patients, providers, and principal 

investigators. This partnership builds on the 

strong tradition of research and evidencedriven continuous quality improvement in 

Veterans’ health care.

References

1. Spelman, J.F. et al. “Post-Deployment Care for 

Returning Combat Veterans,” Journal of General Internal 

Medicine 2012; 27(9):1200-09.

2. Reisinger, H.S. et al. “A Population Approach to 

Mitigating the Long-Term Health Effects of Combat 

Deployments,” Preventing Chronic Disease 2012; 9:110-16.

3. Amdur, D. et al. “VA Integrated Post-Combat Care: 

A Systems Approach to Caring for Returning Combat 

Veterans,” Social Work in Health Care 50 2011; 564-75.

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter 

The VA motto, derived from Lincoln’s second inaugural address, 

includes the obligation “to care for him who shall have borne the 

battle ....” Although some of the injuries associated with modern 

military deployments have changed in the era of OEF and OIF—

for example, the prevalence of blast-related TBI—others such as 

PTSD have been described as far back as the Civil War and earlier. Indeed, some writers have noted classic features of PTSD in 

Homer’s description of the grief of Achilles after the death of Patroclus in The Iliad. 

Given that the health consequences of deployment may persist long after active 

service, post deployment health is a critical area of focus for VA research. Outside 

funders have recently increased their support of research on high-profile conditions 

such as TBI and PTSD, but VA has a unique stake in improving treatment for the full 

range of health problems affecting returning servicemen and women, from tinnitus 

to severe polytrauma. 

Understanding the various manifestations of post-deployment health problems—

and how VHA can best address them—is a fundamental health services research 

challenge. Research is needed to delineate the complicated interactions between 

and among initial stressors, the susceptibility or resilience of returning Veterans, the 

post-deployment environment into which Veterans return, and the models of care 

available to them. Research can help VA learn how to do a better job at the front 

end—the transition from active duty to engagement with VA services—while remaining focused on the goal of helping Veterans successfully reintegrate into a full life 

in their family, their work, and their community regardless of any health challenges. 

Such research requires an understanding of the unique experience of each Veteran, 

his or her needs and capabilities, and the clinical and social resources that can best 

support the individual. This is the ultimate definition of patient-centered care. 

 

David Atkins, M.D., M.P.H. 

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service August 2013
VA Office of Research & Development, Health Services Research & Development Service August 2013

Traumatic Brain Injury (TBI) has been termed 

the “signature injury” of the recent Middle 

East conflicts. However, the defining condition of combat-exposed service members and 

Veterans is better captured by the term “polytrauma,” which is defined as two or more injuries to organ systems or parts of the body that 

create potentially life-threatening injuries and/

or disruption to physical, mental, and psychological functioning. 

Studies have identified TBI, post-traumatic 

stress disorder (PTSD), and pain as the major 

comorbid elements most frequently seen in 

polytrauma injury.1

 Investigators have noted 

that, among Operations Enduring Freedom 

(OEF: Afghanistan through August 2010), 

Iraqi Freedom (OIF: Iraq through August 

2010), and New Dawn (OND: Afghanistan, 

Iraq, and surrounding regions since September 

2010) service members treated at an inpatient

VA polytrauma rehabilitation unit, 80 to 93 

percent were diagnosed with TBI, 81 to 96 

percent with pain, and 44 to 52.6 percent with 

a mental health disorder.2

 And OEF/OIF/

OND Service members and Veterans treated 

for combat-related injuries in VA outpatient

polytrauma programs were diagnosed with 

three or more post-concussive symptoms 67 

to 97 percent of the time, complained of persistent pain 82 to 97 percent of the time, and 

were diagnosed with PTSD 68 to 71 percent 

of the time. A number of other potentially 

disabling concomitant conditions—including 

depression and substance abuse—can also accompany TBI and add to the complexity of diagnosis and management. Approximately half 

of all returning OEF/OIF/OND Veterans 

who sought care from VA presented with one 

or more of these diagnoses; interestingly, more 

than 90 percent of those with confirmed TBI 

also have PTSD, pain, or both diagnoses.3

As with any health condition that has several 

sources of pathology, layers of physiologic and 

psychologic underpinnings, and a complex 

symptomatology, the key to successful understanding and management involves a uniform, 

interdisciplinary, comprehensive team approach. 

This approach is well exemplified by the integrated post-deployment care that characterizes 

VA’s Post-Deployment Integrated Care Initiative 

(PDICI)—an initiative grounded in the basic 

tenets of the PACT (Patient Aligned Care Team) 

model. Drs. Hunt and Burgo-Black eloquently 

outline the evolution of these approaches in their 

commentary “A Transformation in VA PostDeployment Care.” 

While it is important to recognize that individuals with significant persistent polytrauma 

symptoms (or “post-deployment syndrome”) 

may continue to experience difficulties even 

in the best of circumstances, they are likely 

to benefit from the integrated services of 

the PDICI/PACT approach. Often, there is 

no simple or quick solution to the complex 

conditions that may be seen with polytrauma, 

let alone the magnification and uniqueness 

of the symptoms and functional deficits that 

Veterans may experience with two or more 

conditions. An established team of dedicated 

professionals with both primary care and 

specialty care expertise is the most effective approach. Such a team understands the 

subtleties of diagnoses and care for 

post-deployment syndrome and can develop 

a long-term relationship with Veterans. 

VA’s highly developed mental health services, 

polytrauma system of care, and pain management services provide the specialty expertise 

required for particularly challenging or atypical cases.

Ongoing research may provide some insights 

into: (1) the specifics of the initial injury or 

exposure (e.g., blast) on treatment selection or 

outcome; (2) technological advances that will 

enhance diagnostic accuracy; (3) smart or designer pharmaceuticals that can target specific 

sites in the brain, spinal cord, or peripheral 

nervous system to provide symptom relief or 

enhance recovery; and (4) the relative advantages of specific therapies (e.g., exercise, cognitive, behavioral) for variants of polytrauma. 

For the time being, we are fortunate to have 

an established system of care in the Veterans 

Health Administration (VHA) that addresses 

the difficulties of Veterans who have returned 

from combat with complex physical, cognitive, and behavioral dysfunction in a comprehensive and compassionate way. In addition, 

the intense research focus by the military, 

VA, the sports world, and academia on the 

chronic effects of TBI and the potential for 

neurodegenerative decline many years after 

single or multiple TBIs may yield specific diagnostic or management paradigms. 

More likely than not, any advances in research will reaffirm the value of the PDICI/

PACT model of care as outlined in Hunt and 

Burgo-Black’s commentary, which describes 

strategies that Veteran-centric teams can use 

to complement their existing assessment and 

management tools. The increasing adoption 

of this interdisciplinary model of health care 

to diagnose and manage complex conditions 

is pivotal to VHA’s ongoing success in the 

21st century.

References

1. Lew, H.L. et al. “Prevalence of Chronic Pain, 

Posttraumatic Stress Disorder, and Persistent 

Postconcussive Symptoms in OIF/OEF Veterans: 

Polytrauma Clinical Triad,” Journal of Rehabilitation 

Research and Development 2009; 46(6):697-702. 

2. Sayer, N.A. et al. “Rehabilitation Needs of CombatInjured Service Members Admitted to the VA 

Polytrauma Rehabilitation Centers: The Role of 

PM&R in the Care of the Wounded Warrior,” PM&R

2009; 1(1):23-8.

3. Cifu, D.X. et al. “TBI, PTSD and Pain Diagnoses in 

Iraq and Afghanistan Conflict Veterans,” Journal of 

Rehabilitation Research and Development, 2013 (in press).

Response to Commentary

The Value of Polytrauma 

Interdisciplinary Care

David X. Cifu, M.D., National Director, PM&R Program Office,

Office of Rehabilitation and Prosthetic Services, VA Central Office

FORUM — Translating research into quality health care for Veterans 3
In a study of barriers to mental health treatment among recent OEF/OIF Veterans 

who screened positive for PTSD but resisted 

treatment services, Veterans only infrequently 

pointed to stigma as a reason for resisting 

treatment. The majority of Veterans who 

participated in the study had not accessed the 

VA health care system for treatment of any 

type before participating in the study, and 

none had accessed PTSD treatment despite 

screening positive. Participants agreed to an 

hour-long telephone session with a trained 

Ph.D. psychologist to discuss beliefs about 

seeking treatment. During the session, organized from a cognitive-behavioral framework, 

participants were asked about their PTSD 

symptoms, coping skills, beliefs about symptom improvement and beliefs about seeking 

PTSD treatment. Thoughts about seeking 

PTSD treatment were discussed in detail, 

allowing for potential modification of these 

beliefs. Sessions were tailored and individualized. For example, one participant modified 

the belief that he could not tolerate talking 

about his traumatic event, stating that “it’s 

really hard to talk about that day but I think 

about it all the time even though I don’t want 

to and might as well try to get help.”

Beliefs about PTSD Treatment

Beliefs about PTSD treatment elicited during the telephone sessions were analyzed and 

grouped according to theme. Four themes 

emerged, with the first two themes accounting for over 80 percent of discussions. The 

two most frequently discussed barriers to 

treatment related to expectations of treatment (i.e., don’t want a medication, don’t 

want group therapy) and emotional readiness 

(i.e., don’t feel emotionally ready to discuss 

traumatic event).1 The two other themes that 

emerged from the data included stigma and 

logistical issues, such as time and distance to 

the VA.

Arguably, one of the most frequently cited 

statements regarding barriers to mental health 

treatment among returning military personnel 

is that a stigma persists within military culture toward mental health treatment.2

 While 

stigma may have historically been a reason for 

resisting treatment, recent years have seen a 

significant effort to eradicate the perception 

among our warriors. For example, military 

leaders have come forward and admitted their 

own struggles with symptoms of PTSD. In 

addition, and perhaps importantly, our culture has responded enthusiastically as troops 

return home and talk about traumatic memories. In the new age of technology, we have 

been able to give voice to our warriors and 

their stories, and our warriors have received 

the support of family members, friends, and 

fellow warriors. The perception of stigma 

associated with PTSD and PTSD treatment 

might be in flux within military cultures, 

although stigma may still very well exist for 

other mental health conditions such as depression and/or addiction. 

Mental Health Treatment 

Engagement

A change in the perceptions of stigma associated with PTSD and PTSD treatment does 

not necessarily mean higher treatment rates 

among OEF/OIF Veterans. Indeed, interventions to improve mental health treatment 

utilization among Veterans are still warranted. 

Much of the current work focuses on improving rates of mental health treatment engagement, both initiation and adherence, among 

VA users identified as in need of treatment 

when assessed during a visit to primary care. 

Yet, requiring Veterans to go through primary 

care to gain access to specialty mental health 

care may decrease the number of Veterans 

who seek PTSD treatment. 

Many Veterans are willing to seek treatment, 

but they do not fully trust the treatment system, which might be understandable in view 

of the realities and sometimes the complexities of using VA health care. Given that the 

most frequently cited barrier to treatment was 

Veterans’ preference not to be prescribed a 

medication to treat PTSD, any process that 

requires a route through primary care may 

not be in Veterans’ best interests. Co-location 

of services may improve initial engagement 

rates, but VA needs to do more to ensure 

that Veterans receive an adequate dose of 

preferred evidence-based treatments. 

Regardless of system changes that may occur 

within VA, it is important to remember that 

Veterans make decisions regarding the need 

for treatment on their own. Decisions regarding treatment engagement and retention are 

not made easily or lightly. In fact, Veterans 

continually revisit the decision based on a 

combination of beliefs about their perceived 

severity of need, expectations on symptom 

improvement, and perceptions about providers. While it may be unwieldy to conceive of 

a treatment system that is individually responsive to Veterans, Veterans make individual 

decisions on whether or not to engage or 

continue to engage in the VA health care system. Future outreach and/or retention interventions should be responsive to individual 

complexities.

References

1. Stecker, T. et al. “Barriers to Treatment Seeking 

among Veterans of the Wars in Iraq and Afghanistan 

Who Screen Positive for Posttraumatic Stress Disorder,” Psychiatric Services, 2013; 64(3):280-3.

2. Hoge, C.W. et al. “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care,” 

New England Journal of Medicine 2004; 351(1):13-22.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service August 2013

Research Highlight

Barriers to Mental Health Treatment 

among Returning OEF/OIF Veterans

Tracy Stecker, Ph.D., VAMC, White River Junction, Vermont
VA Office of Research & Development, Health Services Research & Development Service August 2013

FORUM — Translating research into quality health care for Veterans 5

Approximately 15 to 20 percent of military 

personnel deployed to Iraq or Afghanistan—

Operation Iraqi Freedom (OIF) and Operation 

Enduring Freedom (OEF)—have experienced 

a mild traumatic brain injury (TBI).1, 2 Symptoms that occur following a mild TBI may 

include headaches, sleep problems, irritability, 

sensitivity to light, and dizziness. While symptoms resolve shortly after injury for the majority of individuals who experience a mild TBI, 

some Veterans experience long-term symptoms. In addition to experiencing mild TBI, 

a substantial number of OEF/OIF Veterans 

have comorbid mental health conditions such 

as PTSD and depression. To identify Veterans 

who might benefit from additional evaluation 

of their symptoms, VA implemented a national 

clinical reminder in 2007 to screen for TBI. 

The reminder includes four questions that address TBI-related exposure and symptoms. 

In our HSR&D-funded study, “Evaluation of 

TBI Screening Processes and Healthcare Utilization” (SDR 08-409), we used VA administrative data to examine the association between 

Veterans’ characteristics, including their comorbidities, and their likelihood of completing 

the clinical reminder for TBI screening and 

achieving a positive result. The study identified 

comorbidities including PTSD, depression, 

and other mental health conditions. We also 

examined VA health care utilization and costs 

for a one-year period. Our sample included approximately 170,000 OEF/OIF Veterans who 

used VA care between 2007 and 2008.

Mild TBI, Comorbidities, and TBI 

Screening

The majority of Veterans in our study were 

white and male, with a mean age of 33 years. 

A substantial number of study participants 

had a diagnosis of a mental health condition. Among Veterans who received a screen, 

18 percent had a PTSD diagnosis, 12 percent 

had depression, and 4 percent had a substancerelated disorder. Overall, 92 percent of OEF/

OIF Veterans received the TBI screen. Veterans 

with PTSD, depression, or substance abuse 

were more likely to receive a TBI screen than 

Veterans without such diagnoses. Of the Veterans receiving a TBI screen, almost 21 percent 

had a positive result. During the screen, the 

most frequently reported symptoms included 

sleep problems, irritability, and headaches. For 

Veterans with comorbid mental health conditions, those with PTSD, depression, anxiety 

disorders, adjustment disorders, or substancerelated disorders were likely to have a positive 

TBI screen. Other characteristics associated 

with a positive screen included male gender, service in the army, and several deployments.3

TBI Screening, Comorbid 

Conditions, and Costs

Veterans who received a positive TBI screen experienced more health care utilization than patients 

who screened negative or did not receive the TBI 

screen. Veterans who screened positive averaged 

3.3 primary care visits compared with 2.6 visits for 

Veterans who screened negative and 1.6 visits for 

Veterans with no TBI screen. The most common 

inpatient admitting diagnosis among all three TBI 

screening groups was PTSD, followed by alcohol 

dependence. Veterans who screened positive also 

received more medications from VA pharmacies than Veterans who screened negative or had 

no screening. Average total health care costs per 

patient for a year were nearly double for Veterans 

who screened positive ($9,610) compared to the 

mean cost for Veterans who screened negative 

($5,184) and nearly three times the costs for Veterans who did not have the TBI screening ($3,399). 

Approximately 80 percent of total health care costs 

were related to outpatient visits. Among Veterans 

who had the TBI screen, total health care costs 

to VA for treating those patients exceeded $918 

million during the 12-month period following 

the TBI screening. While 21 percent of Veterans 

receiving the TBI screen received a positive 

result, they accounted for 33 percent of the total 

cost (nearly $304 million). 

Veterans with comorbidities use more VA services and at higher cost than other Veterans in 

this study. Among the comorbidities, psychoses 

and substance use disorder had the greatest association with costs, followed by depression 

and PTSD. Veterans with psychoses were 222 

percent more likely to be hospitalized, with costs 

$5,094 higher than for Veterans without this 

condition. Veterans with substance use disorder 

had a 220 percent greater likelihood of hospitalization, with costs $2,690 higher than for Veterans without this condition. 

Implications

The TBI screening rate in VA is high. The results demonstrate the continued importance 

of screening both for intervention to treat 

symptoms and for planning to provide for 

ongoing health care needs. We found that a 

substantial portion of care during a 12-month 

period was directly mental health-related, 

particularly for patients screening positive 

for TBI. Over 40 percent of their inpatient 

days in VA facilities were for mental health 

care. The most common admission codes of 

PTSD and alcohol dependence suggest the 

importance of mental health and substance 

use treatment for affected patients. Understanding health care utilization and cost patterns following TBI screening is important 

for policymakers as they address the ongoing 

and future health care needs of returning 

OEF/OIF Veterans.

References

1. Hoge, C.W. et al. “Mild Traumatic Brain Injury in 

U.S. Soldiers Returning from Iraq,” New England Journal of Medicine 2008; 358:453-63.

2. Tanielian, T. et al. “Invisible Wounds of War: 

Psychological and Cognitive Injuries: Their Consequences and Services to Assist Recovery.” Santa 

Monica, CA: RAND Corporation, Center for Military 

Health Policy Research, 2008.

3. Evans, C.T. et al. “An Evaluation of the Veterans 

Affairs Traumatic Brain Injury Screening Process 

among Operation Enduring Freedom and/or Operation Iraqi Freedom Veterans,” PM&R 2013; 5:210-20.

Research Highlight

Mild Traumatic Brain Injury: Screening 

and Comorbidities

Bridget M. Smith, M.P.A., Ph.D., and Charlesnika T. Evans, M.P.H., Ph.D., 

Center for Management of Complex Chronic Care (CMC3), Edward Hines, Jr. 

VA Hospital, Hines, Illinois
FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service August 2013

At times during the conflicts in Iraq and 

Afghanistan, National Guard (NG) and 

Reserve service members have constituted 

as much as 40 to 50 percent of all U.S. 

forces in combat zones. Unfortunately, 

NG Soldiers fare significantly worse than 

active component Soldiers following their 

return home. In a recent study, 41 percent 

of NG Soldiers reported mental health 

symptoms or psychosocial concerns warranting further evaluation or a continuation 

of mental health care at the three-month 

post-return mark.1

NG Soldiers Face Unique 

Challenges, Needs

Although the reasons for higher symptom 

levels among NG Soldiers are unclear, NG 

Soldiers face unique challenges before and 

after deployment. Their training is more 

time-limited than that of Soldiers in the 

active component, and when they return 

from deployments, NG Soldiers are not 

stationed on military bases and have fewer 

built-in supports, such as easy access to 

peers and military health services. Instead, 

NG Soldiers are dispersed throughout 

their home states and must rapidly re-enter 

their civilian communities and civilian jobs. 

In the current economy, they have often 

faced financial difficulties and unemployment, both of which are factors associated 

with increased risk for PTSD.2

To respond to these needs, the Department 

of Defense, National Guard State Organizations, VA, and local communities have 

developed a variety of programs to assist 

returning NG Soldiers with re-integration 

challenges. Peer-to-peer services have 

achieved a particularly high level of acceptance in military circles; as a result, 

VA and other agencies have developed 

and implemented several peer programs for 

NG Soldiers. 

One of these peer outreach programs, 

BuddytoBuddy (B2B), was developed as 

a joint effort by the Department of Veterans Affairs HSR&D and University of 

Michigan faculty, Michigan State faculty, 

Veteran advocates, and National Guard 

leadership. In the B2B program, volunteer 

Veterans from the community are trained 

in communication techniques, confidentiality, and relevant local resources. After 

training, these volunteer Veterans are available in person to Soldiers in their armories 

during drill weekends and by telephone 

between drill weekends. The goal of the 

B2B program is to provide returning NG 

Soldiers with a listening ear and to identify Soldiers with emerging needs such as 

legal, financial, and mental health needs. 

Volunteer Veterans then connect the Soldiers to appropriate resources. Volunteer 

Veterans receive ongoing guidance from 

program staff, and the program contains 

all elements recommended by an expert 

consensus on peer interventions in military 

settings and the Defense Center of Excellence white paper on Best Practices for 

Peer Programs.3

 B2B program staff are 

now working with VA leaders to develop 

plans to expand B2B by partnering with 

VA facilities in other states.

In 2010, the HSR&D Service funded a formative evaluation of the B2B program (SDP 

10-047) to guide ongoing program modifications and facilitate future dissemination 

efforts. We are using an embedded mixedmethods design to assess B2B implementation in the Michigan Army National Guard 

(MI ARNG) and a quasi-experimental approach to assess its efficacy. 

We are surveying all MI ARNG soldiers 

who returned from overseas deployments 

between July 2010 and December 2012 at 

approximately 6 and 12 months following 

their return. To date, we have had a 51 

percent response rate and have collected 

over 1,379 surveys at 6 months and 854 

surveys at 12 months. Data collection 

from MI ARNG units is scheduled for 

completion in October 2013. With the goal 

of guiding implementation and program 

modifications, study investigators meet 

regularly with NG leaders to present 

aggregate data on Soldier well-being and 

participation in the program. 

Peer-to-Peer Program Findings

Preliminary data from our surveys and B2B 

program records indicate that mental health 

symptoms remain an issue for many NG 

Soldiers at 12 months following their return. 

However, the B2B program is achieving 

reasonable levels of uptake within the MIARNG. 

The B2B program currently relies on 83 active volunteers in 35 armories, and the numbers of volunteer contacts with individual 

Soldiers is rapidly increasing. Study surveys 

indicate that approximately 10 to 15 percent 

of returning National Guard Soldiers have 

talked to a volunteer Veteran about re-integration issues, and that Soldiers who have 

talked to volunteer Veterans report high 

levels of satisfaction.

Several papers are in progress that outline 

findings from baseline survey data. A recently submitted paper uses data from this 

Service Directed Project along with 

Research Highlight

Peer Outreach for National Guard 

Soldiers—Assessing the BuddytoBuddy 

Program 

Marcia Valenstein, M.D., M.S., HSR&D Center for Clinical Management Research/

Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, Michigan

Continued on page 8
VA Office of Research & Development, Health Services Research & Development Service August 2013

FORUM — Translating research into quality health care for Veterans 7

The Veterans Health Administration (VHA), 

Health Services Research and Development 

Service (HSR&D) launched two transformational initiatives in the past year, both designed 

to accelerate the translation of VA research 

findings in clinical practice and community settings. The Collaborative Research to Enhance 

and Advance Transformation and Excellence 

(CREATE) program aims to identify and bridge 

significant gaps in health care delivery through 

three to five independent, yet coordinated, 

research projects that are closely aligned with 

health care system problems of importance to 

VHA. The new Centers of Innovation (COIN) 

build from the successful HSR&D Centers of 

Excellence. COIN seeks the rapid advancement 

of the translation of research findings by supporting independent investigators conducting 

novel research as well as groups of investigators collaborating to address significant clinical, 

policy, and methodological questions whose 

answers will lead to improvements in Veterans 

health care and health outcomes. 

Why is a transformational approach needed? 

While health services research has made rich 

contributions to the organization of health care, 

its relevance and usefulness to key decision makers in health care systems is sometimes unclear; 

moreover, the translation of evidence from 

health services research is often slow and inconsistent. Few mechanisms are in place to align 

health care research with the needs of health care 

policymakers and administrators.1

 In this respect, 

CREATE and COIN are transformational; they 

support not only collaborative researchers but 

also the VHA managers, or stakeholders, likely 

to use the results of the research. Researchers 

and stakeholders work together throughout the 

course of a study—from the formulation of 

research questions to the analysis and interpretation of the results. When the research is complete, VHA managers will be poised to use the 

results to improve practice. 

Partnered research is not new and has played 

an important role in several approaches to 

research, including comparative effectiveness research, community-based participatory 

research, and action research.2, 3 In fact, the 

Patient Protection and Affordable Care Act of 

2010 and the creation of the Patient-Centered 

Outcomes Research Institute (PCORI) both 

recognize the importance of engaging community members, patients, caregivers, clinicians, and administrators in research. PCORI’s 

directive calls for it to engage a range of stakeholders as it develops its mission, foci, and 

initiatives, and the researchers funded through 

PCORI are required to engage their stakeholders throughout the research process.

What is new about CREATE and COIN is 

their emphasis on high-level health care system 

partners, such as VHA’s national and regional 

managers and health care executives. Researchers are required to link their studies with those 

who make decisions about how health care is 

organized and resourced. Among the partners 

of the newly funded CREATEs and COINs are 

VHA’s national offices of Public Health, Mental 

Health, Primary Care, Specialty Care, Informatics 

and Analytics, and Women’s Health. Given that 

CREATE and COIN partners are deeply connected with the research, they will likely have a 

greater stake in using the resultant evidence for 

policy development, health care system redesign, 

and implementation of clinical initiatives. 

Even though the emphasis on key decision makers as partners is highly innovative, the focus on 

managers and administrators may suggest limited 

representation of patient and clinician perspectives. To avoid a top-down approach, CREATEs 

and COINs advocate for diversity in stakeholder 

engagement. However, the simultaneous engagement of patients, clinicians, and other stakeholders in research is potentially complex and costly. 

To address such challenges, Hoffman and colleagues proposed several principles for multiplestakeholder participation, including: (1) balancing 

representation among all stakeholder groups; (2) 

ensuring the understanding and acceptance of 

roles across stakeholders; (3) providing expert 

facilitation of discussions; (4) building from connections among stakeholders; and (5) investing in 

sustained stakeholder engagement. The development of these and other principles of stakeholder 

engagement and of new conceptual frameworks 

for partnered research are essential as diverse 

stakeholders participate in research processes.

Both CREATE and COIN aim to influence 

change in the VHA health care system and 

to build evidence that influences health care 

delivery in VHA and beyond. Expanding the 

partnered research vision to include a wide variety of stakeholders will trigger considerations 

such as tailoring the complexity of information 

presented to various stakeholder types (e.g., 

Veterans, clinicians, VHA executives) in order 

to facilitate their informed contributions. However, the involvement of a diversity of partners 

in research will likely permit the alignment of 

research aims with the potentially competing 

needs of patients, clinicians, and managers. 

References

1. Kupersmith J. and S. Eisen. “A New Approach to 

Health Services Research,” Archives of Internal Medicine

2012; 172(13):1033-4.

2. Hoffman, A. et al. “How Best to Engage Patients, 

Doctors, and Other Stakeholders in Designing Comparative Effectiveness Studies,” Health Affairs 2010; 

29(10):1834-41.

3. Kitson, A. et al. “Knowledge Translation within a 

Population Health Study: How Do You Do It?” 

Implementation Science 2013; 8:54.

Organizational Profile

Accelerating Innovation and Translation 

through Strategic Partnerships:

Collaborative Research to Enhance and 

Advance Transformation and Excellence 

(CREATE) and Centers of Innovation (COIN)

Sara J. Knight, Ph.D., Deputy Director, Health Services Research and Development,

Office of Research and Development, Department of Veterans Affairs
Peter L. Almenoff, M.D., FCCP, 

Director of Operational

Analytics and Reporting, Office 

of Informatics and Analytics, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

Director, HSR&D

VA Central Office,

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse

Executive, VA New York

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A.,

Director, VA HSR&D Center

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc.,

Past Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H.,

Director of Clinical Analytics 

and Reporting, Office of

Informatics and Analytics, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach,

Long Beach, CA

Richard Owen, M.D., Director, 

VA HSR&D Center of

Excellence, Little Rock, AR

DeAnne M. Seekins, MBA, VA 

Medical Center Director,

Durham, NC

Frances Weaver, Ph.D.,

Director, VA HSR&D Center 

of Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

data from earlier cross-sectional surveys 

completed by study investigators to assess 

changes in reported barriers to care over 

time. The percentages of Soldiers reporting treatment barriers related to negative 

beliefs about mental health treatment or 

stigma declined significantly over the three 

periods of data collection. 

Study of B2B implementation continues, 

and more complex analyses that examine 

factors influencing various units’ adoption 

of B2B are pending. Our goal remains to 

use the rich data being collected to inform VA Central Office of Mental Health 

Services, the DoD, and other interested 

organizations about peer program implementation and sustainability in addition 

to providing preliminary data on program 

effectiveness. 

References

1. Milliken, C.S. at al. “Longitudinal Assessment 

of Mental Health Problems Among Active and 

Reserve Component Soldiers Returning From the 

Iraq War,” Journal of the American Medical Association

2007; 298(18):2141–8. 

2. Riviere, L.A. et al. “Coming Home May Hurt: 

Risk Factors for Mental Ill Health in US Reservists 

after Deployment in Iraq,” British Journal of Psychiatry 2011; 198:136–42. 

3. Money, N. et al. Best Practices Identified for Peer Support Programs. Washington DC: Defense Center of 

Excellence, 2011. 

FORUM

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