“The idea was that we wanted to disseminate expertise,” Kudler explained. “And expertise is not just what you can get in a book.”
He offered the example of a patient diagnosis that might lead to a prescription for “an SSRI [selective serotonin re-uptake inhibitor] like Citalopram” but some uncertainty surrounding dosage adjustments.
“We want the experts on site, so you know who to ‘curbside’ to get the answer to questions like that,” he said.
However, for those situations where veterans want to and can be seen in community provider settings, VA has recently created a Community Provider Toolkit website that offers free training for nearly any health care provider discipline on military cultural competence. The training is arranged in four separate modules – providing basic familiarization with the military and related issues – and accredited for up to eight hours of continuing education credits. More than 16,000 community providers participated in 2014.
He continued, “To take the process even farther, the [VA’s] National Center for PTSD has developed the PTSD Consultation Service, so that any clinician in the VA, if they didn’t know who to call in their facility – maybe they were new or were at a great distance where they couldn’t access a local expert – could pick up the phone and call a consultation center where they could get expert advice on how to manage the case they presented.”
Congress further expanded the consultation process last year with funding to allow the National Center to provide similar consultation to community providers working with veterans who may not be enrolled in the VA system.
“We’re not going to tell people to do something,” Kudler clarified. “But we will connect them to a body of know-ledge and possibly use it as an opportunity to also ask if the provider has considered coordinating this veteran’s care with VA. For example, did you tell me that the veteran can’t afford Citalopram? Well, did you know that the VA would pay for it if he or she enrolls in VA? And we can do neuropsychological testing. You say that he might have traumatic brain injury (TBI). Well, we can screen for that. We can do a lot of workup that you might not be able to do in your part of the world or that the patient can’t afford with their insurance.”
The significance of VA’s community resource outreach was further expanded by the 2015 Veterans Choice and Act, which identified distance or appointment delay situations in which veterans could seek care from participating non-VA providers.
Kudler acknowledged some appointment delays in receiving VA mental health care, but quickly asserted that the situation is “way, way worse” in many community settings.
“What the VA secretary has been saying is, when it comes to mental health care in America, the VA is ‘the canary in the coal mine,’” he said. “If, with our huge integrated mental health program, we can’t see people within 30 days of when the patient wants to be seen, what’s happening in the community? In many cases, they aren’t being seen at all. In many, many cases, they can’t be seen. Period.”
However, for those situations where veterans want to and can be seen in community provider settings, VA has recently created a Community Provider Toolkit website that offers free training for nearly any health care provider discipline on military cultural competence. The training is arranged in four separate modules – providing basic familiarization with the military and related issues – and accredited for up to eight hours of continuing education credits. More than 16,000 community providers participated in 2014.
Emphasizing that “most people coming through military service, including deployments, will not develop a mental health diagnosis,” he added, “Everyone involved in the deployment cycle and everyone transitioning between military and civilian life faces significant stress, as do their families – even if it’s ‘good stress,’ like new babies, new jobs, new opportunities, or moves to new communities. But it’s significant stress. And sometimes this will require help from somebody who knows how to help.
“We established this training with the Department of Defense and we put it up from the National Center,” he noted. “It’s actually the first public-facing education program of its kind ever done by VA.”
He said that the critical need for this type of program is supported by one recent study that found “only 13 percent of all community providers in America have the military cultural competence and clinical skills to provide basic care to veterans. Whereas among people who worked in the VA, it was 70 percent, which is still not as good as it ought to be but is a lot better.”
The summer of 2015 also witnessed the third annual round of Community VA Mental Health Summits at every VA medical center, to discuss things like the military competence training.
“So what we have done is to establish the largest integrated mental health system in the country,” Kudler summarized. “And PTSD is one of the things it drills for. We teach providers in our system and we reach out to train other providers.”