Veterans Affairs



Advisory Committee on the Readjustment of VeteransStrategic Meeting SummaryTuesday, September 11 – Thursday, Septermber 13, 20181. Day 1: Summary of Primary VHA Presenters and Agenda Topics Formally Presented/Discussed:PresenterTopic of PresentationsOpening discussion chaired by Cathleen Lewandowski, Ph.D. Committee Chair, Charles M. Flora, LCSW-C, Committee DFO, and Richard Barbato, MSW, Committee Alternate DFO.Note #1: Alfred Ozanian, PhD, RCS Deputy Chief Officer, met with the Committee on Wednesday 13, 2018 for introductions and discussion. Note #2: Sherry L. Moravy, MPH, RCS Planning and Policy Officer, participated in the meeting on all three days. Note #3: On Tuesday, September 11, 2018, the Committee received three visitors from the U.S. Senate Committee on Veterans Affairs. Annabell McWherter, Legislative AidPatrick McGuigan, Professional Staff Sophie Friedl, Legislative AidNote #4: The Committee has been approved for a 3rd meeting in FY 2018. At various points during the designated executive meeting sessions contingency plans were discussed. A field meeting is being planned for a Vet Center with sufficient conference space and electronic equipment for teleconferenceing. San Antonio, TX is one Vet Center currently under condsideration. A field meeting would enable Committee members to strategically interact with local Veterans, Vet Center staff and relevant providers from the local VA medical center. The Committee agenda could also include national program updates via teleconferencing. The first week in December 2018 was identified as the meeting date. 1. Review of Committee agenda and handout materials with strategic implications for further development: Committee CharterAnnual Assessment of Committee Activities for 2017Annual Committee Operations Plan for 2018Committee 18th Annual Report and VA ResponseCommittee 19th annual Report and VA ResponseStrategic Meeting Summary for March 2017Strategic Meeting Summary for February 2018MOU developed by RCS in partnership with the Office of Mental Health and Suicide Prevention (OMHSP)MOU developed by RCS in partnership with the Office of Academic Affiliations (OAA) for Vet Center student intern placementsCurrent VHA Organization ChartsLee A. Becker, Chief of Staff, Office of Veterans Experience.Jacob Gadd, for Keita Franklin, Ph.D., Acting National Director for Suicide Prevention.1. Mr. Becker presented the background and current status of VA’s Office of Veterans Experience. This office was developed under the leadership of the former Secretary of Veterans Affairs, Robert McDonald. The primary focus of this office is to develop procedures for improving Veterans’ customer experience at all points throughout the Veteran’s journey following departure from the military: initial engagement with the VA, arrival at a VA facility, the VA appointment (healthcare and/or benefits), departure from the VA facility, and post appointment follow-up. 2. Mr. Gadd provided an overview of VA’s response to Executive Order 13822 which instructed VA, DoD, and DHS to develop a Joint Action Plan to support Servicemembers during their first year of transition into Veteran status after leaving the military. Within VA the plan is organized under VHA’s OMHSP. The plan is to provide support to departing Service members during the first critical year of their transition into Veteran status. The plan includes three points of focus: (a) general engagement and supportive guidance for the entire new Veteran population, (b) supportive intervention and referral for those Veterans demonstrating need for VA services, and (c) detection and immediate services for those presenting at high risk for mental health and suicide prevention services. Of note was the inclusion of the Readjustment Counseling Service (RCS) into this plan via the RCS Chief Officer’s initiative to build and expand partnerships with the National Guard systemwide. David Carroll, Ph.D., Executive Director, OMHSP, (10NC5)Michael W. Fisher, MSW, Chief Readjustment Counseling Officer(10RCS) Substantive presentation highlighting the following operational areas for OMHSP and RCS:1. Dr. David Carroll provided an overview of current issues regarding VA’s OMHSP: (a) past year accomplishments of the NC/PTSD inclusive of a number of initiatives related to PTSD treatments available to Veterans, (b) implementation of Executive Order 13822 to support transition of Veterans to civilian life immediately following departure from active military service, (c) implementation of service delivery to OTH Veterans with other than honorable discharge, (d) stepped care levels Veterans with opioid use disorder, and (e) the implementation of section 506 of the Mission Act requiring VA to have two mental health peer specialisits on all Patient Aligned Care Teams (PACTs). 2. Mr. Michael Fisher presented the Committee with the current status of RCS including the following key issues:a.The organizational transition of RCS from 7 Regions to 5 Districts and associated transition to a single point of service with RCS specific HR and fiscal services has been completed as of April 2018. b. The RCS Vet Center footprint currently consists of over 2,200 staff and 300 Vet Centers, 81 Moble Vet Centers (MVCs), 19 Vet Center Outstations and over 900 Community Access Points (CAPs) providing service on a weekly or monthly basis at points distant from existing Vet Center facilities. c. Currently RCS is focusing on national policy development, standardization and team building. d. A major step in staff development was made through the resumption of RCS staff face-to-face training in 2018 with a total of over 30 individual 3-day training episodes focusing on all Vet Center staff cohorts: office managers, outreach specialists and counselors. e. Status of recruitment and hiring of RCS national leadership positions: District and National. It is of note that all RCS district leadership positions have been filled and all national positions are either on board or selected and awaiting respective start dates. f. Vet Center productivity standards regarding workload outcome measures for both time and Veteran client encounters was presented. In a normal 40 hour week, Vet Center counselors are expected to spend 17 hours in direct contact with Veteran clients providing readjustment counseling: individual, group and/or family. The 17 hour weekly time measure is expected to generate 25 encounters (1.5 client visits per hour) which accommodates plural encounters for counselors providing group readjustment counseling. g. As presented, Vet Center productivity system-wide has increased over a 2-year period by 30% in visits and 18% in unique clients served. h. RCS continues in active partnership with the Office of Mental Health and Suicide Prevention (OMHSP) through activation of the mutually signed MOU for collaborative suicide prevention between the RCS and OMHSP inclusive of coordination of the unique responsibilities of each office for access, education and data exchange. Paula Schnurr, PhD, Executive Director, VHA National Center for PTSD (NC/PTSD)LeAnn E. Bruce, PhD, LCSW, National Program Manager, Intimate Partner Violance Assistance Program (IPVAP), VHA Care Management and Social WorkCommittee Strategic Discussion Day #11. Dr. Schnurr provided the Committee with a presentation on research findings regarding VA PTSD treatment modalities. Her presentation was in follow-up to a more broad scope presentation on the NC/PTSD she provided the committee at their February 2018 meeting. The data presented indicated that trauma based psychotherapies such as CPT, PE, and EMDR have more positive outcomes than other therapy applications or medication treatment. 2. Dr. Bruce provided the Committee with a presentation of the historical development, purpose, values, and current progam activities of VHA’s IPVAP to include providing effective treatments and educational programs regarding domestic violence. Key strategic points included establishing referral networks with Vet Centers for family readjustment counseling and establishing partnerships between the Vet Centers and the IPVAP coordinators stationed at each VA medical facility. Following topics were discussed regarding their value to the readjustment of combat-theater Veterans and potential for development into recommendations for the 20th Annual report:1. The establishment of Vet Center Community Access Points (CAPS) on college and university campuses to outreach and engage Veterans primarily accessing educational/occupational readjustment challenges, many of whom are also struggling with the psychological aftermath of military conflict.2. The Committee again underscored the vital significance for conducting a military history for all combat theater Veterans accessing VA services, not only for those accessing readjustment counseling at a Vet Center. Military history is a primary tool for understanding the cultural differences among the various generations of combat theater Veterans, which leads directly into the need for differential tailoring of Veterans’ mental health treatments and/or readjustment counseling service plans. Vet Centers will need to continuously adjust their service practices to meet the needs of new Veteran groups without losing the traditional values of a relaxed, easy to access, community-based, non-medical environment. 3. For the purposes of providing readjustment services, it is also important to augment the military history by including assessments of the Veteran or Service member’s pre-military social history and post-military adjustment to family, work and community. 4. From the information presented by the RCS Chief Officer, it is the Committee’s understanding that RCS is currently prioritizing policy improvement, standardization and team building with attention to the following:Completion of the new RCS policy directive, Improving timeliness for clinical recording,Ensuring consistency for the Vet Center staffing model,Enhancing Vet Center staff motivation and skill through training, supervision, consultation and recognition, Reinforcing all Vet Center communication pathways: within the Vet Center, between Vet Centers, within the RCS hierarchy, and with community alliances, and Improving the Vet Center client record platform and possibly creating a closer integration with the VHA medical record. However, the Committee notes that whatever recording platform is used, it is essential for the Vet Centers to maintain a separate system of records with maximum confidentiality protection. 5. The Committee also noted that Vet Center counselors are assigned a weekly productivity capacity of 17 hours in direct interface with Veteran clients to generate 25 encounters (1.5 client visits per hour). Although the Committee recognizes the necessity for defining capacity for measuring the quantity of care provided, they also noted the need to balance outcome measures for quantity with traditional Vet Center therapeutic culture to ensure a strategic mix of quantity and quality. 6. In the face of current procedural standardization and new initiatives, the Committee noted the continuing need for the Vet Centers to maintain their traditional non-medical, community-based culture: Maintain an open door policy where Veterans, Service members and their families are welcome to drop by without an appointment,Promote local Veterans’ sense of ownership,Create active alliances embedding the Vet Center into the community as an active partner,Maintain a Vet Center interior décor that reflects appreciation for the military and the history of national combat theaters,Maintain open areas within the Vet Center interior suitable for Veterans, Servicemembers and their families to gather, relax, socialize, and plan for events of particular meaning for the local Veteran community.7. The Committee noted the ongoing challenges for the Vet Center non-medical service mission organized under separate line authority within VHA, which require active collaborative partnerships with other VA services for successful outcome. This collaboration includes bilateral referrals and active case coordination. Vet Center collaboration with VA medical facilities is of particular relevance for coordinating PTSD services for Veterans and Servicemembers accessing both readjustment counseling and VA mental health care. 8. The Committee noted a similar need for collaboration between VA and DoD, primarily via an active interface within the JEC. This is of value for addressing the priority for serving OTH Veterans where less than honorable discharges that are probably PTSD related. This perspective is also of value for providing services to active military Service members with PTSD from MST and/or combat. 2. Day Two: Presenters and Committee Strategic DiscussionsAnne Dunn, Deputy Director, VA Homeless Programs, Acting Director, VA Veterans Justice Programs.Ms. Dunn provided the Committee with an in-depth overview of Veterans Justice Programs with particular attention to Veterans Justice Outreach activities in conjunction with state organized Veterans Courts. The Committee’s strategic interest is in overcoming barriers to care for combat theater Veterans having legal readjustment problems. The Committee also sees the need for a more active partnership between Vet Centers, VA Veterans Justice Outreach and state operated Veterans Courts system-wide. Kenneth R. Jones, PhD, Director, Associated Health Education, Office of Academic Affiliations (OAA).Dr. Ken Jones briefed the Committee on the history of VA’s OAA for training healthcare professionals and on its current organizational structure. To standardize student intern placements in VA Vet Centers, primarily for social work and psychology students, OAA collaborated with RCS to authorize student interns rotations at Vet Centers through a formal MOU to be implemented by the Vet Center Director and the Designated Educational Official (DEO) at each VA support medical facility. Dr. Jones presented data indicating that Vet Center intern placements at Vet centers has doubled since 2016 from 15% to 30% of Vet Centers having a signed MOU with their support facility DEO. The Committte is encouraged by the current discussion between OAA and RCS to promote more flexible rotations that would optimize the portion of the internship spent at a Vet Center. This would enable students with an interest in readjustment counseling in the Vet Center setting to spend more time at a Vet Center. It is the Committee’s belief that this will provide an investment in Vet Center staffing by providing an avenue for training qualified Veteran readjustment counseling providers and by contributing to the educational readjustment of individual combat Veterans. Richard A. Stone, M.D., VHA Executive in ChargeDr. Stone engaged the Committee in active discussion focusing on the following issues:1. The need to find, outreach and affectively engage the 14 Veterans a day who commit suicide without ever having had any contact with VA.2. The need to re-establish trust in VA.3. The need to develop VA into an established learning organization.4. The need to modernize the Veterans Health Record (VHR).5. The need to promote employee empowerment for solving local problems and implementing local initiaitives, as oppossed to the current overdependence on a centralized bureaucracy. 6. The need for VA to establish cultural connections with all Veteran groups: gender, generational, ethnic, socioeconomic, etc. Committee Strategic Discussion Day #2Following topics were discussed regarding their value to the readjustment of combat-theater Veterans and potential for development into recommendations for the 20th Annual report:1. The Committee noted the need for VHA to sharpen its program focus regarding cognitive services for Veterans with war-related brain injuries (TBI) similar to what VHA has developed in the area of psychological counseling for Veterans with PTSD. It was pointed our during the meeting that currently TBI is an immature science pertaining to both diagnostic acuity and treatment regimens.2. Similarly the Committee noted the need for the Vet Centers to improve their assessment procedures for the physical wounds of war: TBI, burnpit inhalations, and other physical wounds having implications for physical healing and psychosocial adjustment. The latter may include post combat changes in attitude such as resentment, shame and alienation. Vet Center services in response to positive assessment outcomes for physical wounding would entail, referral for VA medical care, follow-up and case coordination. 3. Without changing the essential design features of the Vet Center service mission, the Committee noted the need to adjust its service delivery to meet the specific needs of the OEF/OIF/OND combat theater Veterans. 4. In addition to generational culture competency, the Committee noted the core value for all VA service programs to be educated in all areas of cultural competency characteristic of the national Veteran population: gender, ethnicity, socioeconomic orientation, etc. 3. Day Three: Presenter and Committee Strategic DiscussionsWendy Torres, Acting Exective Director, VA Office of Transition and Economic DevelopmentMs. Torres provided the Committee with a status briefing for the new VBA Office of Transition and Economic Development (TED). This program comprehensively addresses military to Veteran transition though management of the VA/DoD/DoL Transition Assistance Program. However, in addition this new progam makes strategic use of Chaper 36 career counselors to empower Veterans to achieve maximum economic well-being. Strategic to the Committee’s charter is this new program’s focus on addressing the economic readjustment problems of combat theater Veterans. Committee Strategic Discussion Day #3Following topics were discussed regarding their value to the readjustment of combat-theater Veterans and potential for development into recommendations for the 20th Annual report:1. Review of the Committee’s Annual operations plan for 2018. In this arena the Committee noted the following achievements:a. RCS’s plan to promote staff training in EBT, but under no circumstances to replace traditional readjustment counseling with a 12 session manualized approach. Rather Vet Center counselors would be encouraged to dissemble the EBT tools for application as clinically indicated with specific Veteran clients. Manualized EBT therapy would remain available for Veteran groups whose needs coincided with this type of approach. Traditional readjustment counseling recognizes the need for long series of continuous service by some Veterans and for other Veterans the need for episodic sequences of therapeutic encounters as new readjustment issues arise throughout the life cycle. b. The pending RCS policy directives have been revised and incorporated into one document with administrative and clinical policy guidance, and it is in the last stages of review prior to being published though VHA. Following the final release of the new RCS policy directive, the Committee notes the need for cross referenceing it with the Vet Center site visit protocols and the electronic client record in RCSNet for consistency and accuracy. The latter may require strategic revisions to either or both the site visit protocols and/or the client record. 2. Review of VA’s responses to the Committee’s 19th Annual Report which were primarily in agreement with the Committee’s recommendations. 3. In light of the briefing from VA’s Veterans Justice Program, the Committee underscored the significance of the availability of Vet Center readjustment counseling to Veterans involved in Veterans Court and plan to recommend that RCS actively pursue increasing its outreach and readjustment counseling services to VA VJO and Veterans Courts accordingly. 4. The Committee conducted substantive discussions regarding suicide prevention to include the following issues and perspectives:The need for standardizing the Vet Center risk assessment procedures with clear guidelines for consultation and possible referral for positive outcomes involving threats to client safety. The Committee’s concurrence with RCS’s proposal to incorporate the ‘Peer Review’ within its procedures for critical incident quality management. Currently the Vet Centers apply the Mortality and Morbidity (M&M) quality review for cases of completed suicides and homicides. The need to disseminate best practice findings from completed Vet Center M&M quality reviews and peer reviews. The need to assess the suicide risk factors related to the Veteran’s family readjustment dynamics.For all completed Veteran suicides, the need to assess precipitating causes and the mode of death in relationship to the Veteran’s combat military experience and post-war homecoming. As the Committee understands it, VA’s current challenge is to find and engage the 14 out of 20 daily Veteran suicides who have never accessed VA care. The Committee was informed that the 2015 Veteran suicide report, cross referenced by CDC, DoD and VA, had been received by the OMHSP. Although the report contains valuable data, its findings are not currently useful due to the delay in VA’s reception of the report. Of note is the finding that more Veteran suicides were reported for Vet Center clients than were recorded by the RCS national service support office’s tracking of all completed suicides and M&M quality reviews conducted during the fiscal year. In response to the above finding, the Committee notes the need for the Vet Centers to establish a more active system of follow-up communication with former Veteran clients who have either: (1) dropped out of readjustment counseling, or (2) have completed a regimen of planned readjustment counseling. All means of communication should be considered for this purpose to include telephone calls and/or friendly letters. Vet Center life time eligibility is predicated on the fact that readjustment problems may reoccur and/or new readjustment problems may emerge at various stress points throughout the Veteran’s lifecycle. 5. Thus in summary, the primary issue at hand for Vet Centers is to improve the practices for finding and engaging Veterans and Service members sufficient to overcome all risk factors leading to a successful readjustment. Cathleen A. Lewandowski September 21, 2018Committee Chair Certification Date ................
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