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Essential outreach: Expanding mental health support for rural veterans


David Carroll


Thomas F. Klobucar


Kendra Weaver


One in every five service members returns home from combat with at least one serious mental health issue. Successful treatment often requires specialized provider training to meet the unique needs of service members and veterans. Combine those factors with the reality that there are approximately 16 psychologists for every 100,000 rural residents, and this just begins to offer a glimpse into the complexities and challenges of managing mental health care for rural veterans.

“Many veterans come back from service with mental health needs that differ from those of the general population. With fewer mental health providers per patient in rural America, there is an acute need to address rural provider shortages, retain what workforce there is, and find ways to compensate for shortages using innovative solutions,” explains Thomas F. Klobucar, Ph.D., U.S. Department of Veterans Affairs’ (VA) Office of Rural Health (ORH) acting executive director.

Military-specific challenges

ORH engages VA’s clinical offices, including the Office of Mental Health and Suicide Prevention, to deliver enterprise-wide initiatives that increase rural veterans’ access to care and foundational medical services. These nearly 50 national initiatives rely on telehealth, community outreach, online and phone-based resources, and workforce-centered programs to get the veteran to care or care to the veteran.

“Mental health conditions that veterans face include post-traumatic stress disorder (PTSD), substance use disorders, dementia, depression, and suicidal crises. These can be precipitated by military service, the transition from military life, aging, or social determinants such as employment and financial issues,” explains David Carroll, Ph.D., VA Office of Mental Health and Suicide Prevention executive director of mental health operations.

These problems are compounded by common health care access challenges in rural communities, including geography, distance, lack of transportation, and fewer health professionals to support the higher percentage of rural veterans who struggle with mental health conditions. “More than 85 percent of rural residents live in a mental health professional shortage area,” says Carroll. “This is very troubling, because veterans who reside in rural communities are more likely to have current or lifetime depression and are at significantly higher risk of suicide.” In addition, rural community providers report feeling less knowledgeable than urban providers about PTSD, substance use disorders, depression, and suicide prevention.

Expansion of mental health programs

To improve rural veterans’ access to mental health care, ORH has increased funding for 10 enterprise-wide mental health initiatives by 83 percent in fiscal year 2018 — from $28.9 million to $53 million. “Our expansion of rural-focused mental health initiatives reflects the secretary’s — and entire department’s — increased commitment to aggressively address suicide prevention through a more comprehensive approach to mental health care,” Klobucar says. “This funding builds the rural mental health workforce, provides specialized training to clinicians on military-specific issues, and helps find ways to bring in the community to play a role in identifying and supporting rural veterans’ mental health.”

“We are very grateful for the expansion and what it means,” adds Kendra Weaver, Psy.D., VA Office of Mental Health and Suicide Prevention senior consultant for mental health clinical operations. “This helps us provide services to rural veterans in underserved areas and bring mental health care to veterans at their preferred location.”

A few of the programs that benefit from ORH’s funding include:

  • Expansion of VA Telemental Health Hubs to connect mental health specialists with rural-serving sites where veterans require same-day or urgent access to mental health services and access is limited due to provider shortages or other barriers.
  • Expansion of social work in Patient Aligned Care Teams that provide funding for integration of rural social workers on interdisciplinary care teams to ensure that patients who are discharged are connected with a social worker for follow-up.
  • Web-based behavioral support that combines principles of cognitive behavioral therapy with interactive e-learning techniques to provide all veterans with tools to overcome mental health challenges such as depression or PTSD.

Suicide prevention

VA Secretary David Shulkin calls veteran suicide a public health crisis, as an estimated 20 veterans commit suicide every day — six of whom are enrolled in the VA health care system. As such, it’s VA’s top clinical priority.

To help reach VA’s goal to reduce and eliminate veteran suicide and Be There for Veterans, a formal programmatic effort that includes five key components is underway:

  1. Improve transition with outreach to veterans to encourage VA health care engagement and transition services for separating service members;
  2. Know all veterans by understanding their needs so the VA can reach them as soon as possible;
  3. Partner across the community, fostering local, state, and community relationships;
  4. Lethal means safety counseling to help veterans with issues including overdose education, safety planning for suicide prevention, and distribution of gun locks;
  5. Improve access to mental health treatment in underserved areas and provide therapy for conditions in need of treatment.

Part of ORH’s commitment to preventing veteran suicide is expanded training for clinical providers who may not be familiar with identifying and treating mental health issues, PTSD, and preventing suicide. This training helps improve health care professionals’ ability to identify and treat the underlying conditions. Another initiative educates veterans and family members to help them understand warning signs, where to get care, and how to get help through VA.

Reaching more veterans though telehealth

To help veterans access mental health care closer to home, VA has expanded telehealth funding to connect providers virtually to wherever the veteran resides or to a nearby facility. The 11 Telemental Health Hubs plan to add approximately 30 more sites of care in their service delivery in fiscal year 2018. Telemental Health Hubs are networks that connect mental health specialists with rural sites where veterans receive access to evidence-based mental health services. Telehealth services are available to veterans via audio or video solutions in a communitybased outpatient clinic, mental health clinic, at work using an app, or at home. “Our goal is to provide the right care in the right place at the right time, and using telehealth equipment helps us do that,” Weaver says.

The VA’s 11 Telemental Health Hubs provide services to more than 200 sites across the country and have already served more than 23,000 veterans since the program began in 2016. Many rural veterans are receptive to telehealth options, and the program has contributed to reductions in wait time, decreased travel costs for veterans, and better access to basic mental health care and specialty services (e.g., treatment for opioid use disorder).

“Rural veterans need to know there are a number of resources that exist, whether it’s a phone call, resources on the web, or being seen by a mental health provider. In the case of telehealth, veterans may be surprised to learn they can have a mental health visit directly in their homes,” says Carroll.

Focus on community connections

The shortage of providers and health care professionals in rural areas is a continuing problem, and the expansion of innovative mental health programs provides a new opportunity to help rural communities bridge the gap. “We’re interested in increasing partnerships with communities in rural areas where we know family and community are particularly important,” Weaver says.

For example, the Community Clergy Training Program provides training to leaders in churches and places of worship, community centers, and clergy programs so they can help veterans access care when they need it. Community leaders are not trained to diagnose mental health conditions but rather to recognize common symptoms of crisis and connect veterans with the appropriate VA and community resources.

“Partnerships like the one we have with ORH and rural communities will continue to be an increased focus. Through technology and training, we’re also helping rural veterans take an active role in their health care by offering opportunities for self-care and virtual care options for veterans. Our focus is on treating the whole person and continuing outreach to veterans who are not in care and reaching them wherever they are,” Carroll adds.

To improve rural veterans’ access to mental health care, ORH increased its mental health funding of 10 enterprisewide mental health initiatives by 83 percent.

$53 Million in ORH-funded mental health programs

1. Telemental Health Hubs connect mental health specialists with rural-serving sites where veterans require same-day or urgent access to mental health services and where access is limited due to provider shortages or other barriers.

2. Social Work in Patient Aligned Care Teams (PACT) expands integration of rural social workers into the PACT model to improve care coordination for rural veterans and their interdisciplinary care teams.

3. Advanced Care Planning via Group Visits connects veterans to Advanced Care Planning experts who help them develop a plan to address how health care decisions will be made if they are unable to communicate.

4. Rural Access Network for Growth Enhancement provides intensive case management services including homeless outreach to seriously mentally ill veterans in rural areas.

5. Community Clergy Training Program educates rural community clergy on available VA health care resources and trains rural clergy to recognize common symptoms of post-traumatic stress disorder, military sexual trauma, and readjustment issues in veterans returning to their rural communities upon separation from military service.

6. Rural Veteran Suicide Prevention Program connects veterans to comprehensive suicide prevention services and resources through enhanced education, public awareness campaigns, community training, crisis support, firearm safety, and care management for highrisk individuals.

7. Military Sexual Trauma Web-Based Therapy delivers specialized mental health care directly to veterans’ homes through telehealth to care for those who have experienced military sexual trauma.

8. Simulation-Based Learning for Suicide Prevention uses the VA SimLEARN infrastructure to train rural clinicians and improve identification, interaction, and treatment of rural veterans at risk for suicide.

9. Vets Prevail Web-Based Behavioral Support provides veterans who suffer from depression or PTSD with tools to address these challenges.

10. Support for Caregivers of Veterans provides caregivers of medically vulnerable rural veterans with Resources for Enhancing All Caregivers’ Health (REACH VA), including personal telephone-based support.

Image © iStock.com/Steve Debenport

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