The United States Military and Veterans Administration Health Systems

The United States Military and Veterans Administration Health Systems paper

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Contemporary Overview and Policy Challenges

John S. Murray

“No one who fights for this country should ever have to fight for a job, or a roof over their head, or the care that they have earned.”

President Barack Obama

The U.S. Military Health System (MHS) provides a number of important health care services to as many as 8.3 million service members, military retirees, and their families (Murray & Chaffee, 2011; The Kaiser Foundation, 2012). Military health care is provided by approximately 140,000 military, civilian, and contract personnel working around the globe at 59 military treatment facilities (MTFs) capable of providing diagnostic, therapeutic, and inpatient care. Additionally, care is delivered at hundreds of military outpatient clinics and by pri­vate sector civilian providers (Government Accountability Office [GAO], 2012; Murray & Chaffee, 2011).

Military nursing consists of several components: active duty, reserve, National Guard, enlisted medical technicians, and federal civilian registered nurses. The Army Nurse Corps is comprised of 40,000 nursing team members, whereas the Air Force has 18,000 and the Navy approximately 5,800 (U.S. Senate Committee on Appropriations, 2012). Active duty military nurses in all armed forces must have a bachelor’s degree in nursing (BSN) from an accredited school to serve in the military.

The MHS has two missions (Figure 39-1):

• A military readiness mission: supporting war­time and other deployments (GAO, 2012; Murray & Chaffee, 2011).

• A health care benefits mission: providing medical services and support to members of the armed forces, retirees, and their dependents (GAO, 2012; Murray & Chaffee, 2011).

The Veterans Health Administration (VHA) is home to the United States’ largest integrated health care system consisting of 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers, and residential homes for disabled veterans. More than 239,000 staff, including 53,000 licensed health care clinicians, work to provide comprehensive care to more than 8.3 million veterans each year at these facilities. The VHA nursing team consists of 77,000 personnel nationwide composed of registered nurses, licensed practical/vocational nurses, and nursing assistants. Of these, approximately 5440 are advanced practice nurses (Certified Registered Nurse Anesthetists, Nurse Practitioners, and Clinical Nurse Specialists). A BSN degree is not a requirement to work for the VHA (U.S. Department of Veterans Affairs Office of Nursing Services, 2010). The VHA’s primary mission is to honor America’s veterans by providing exceptional comprehensive care that improves their health and well-being. It accomplishes this benchmark of excellence by

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providing exemplary services that are both patient centered and evidence based (U.S. Department of Veterans Affairs, 2013a). The United States Military and Veterans Administration Health Systems

FIGURE 39-1 The Military Health System Mission.

The MHS and VHA Budgets

The National Defense Authorization Act (NDAA) is passed by Congress annually and specifies the overall budget for the Department of Defense (DoD), which includes funding for the MHS. Funding supports the delivery of health care to service members and their families as well as supporting education and training of military medical personnel, research, and purchasing medical equipment and supplies for MTFs and clinics (Murray & Chaffee, 2011). Each year, senior military nursing leaders speak before Congress regarding accomplishments and challenges over the previous year as well as identifying what new programs and policies are needed. In 2012 the Chief of the Army Nurse Corps presented information to support the need for a new trauma-training program for nurses. This program would allow the nurses to continue to develop their full capability to manage critical trauma patients across the battlefield. In response, Congress provided funding to support the development of the Army’s first Trauma Nurse Course that prepares nurses for the ever-changing traumatic injuries treated on the battlefield (U.S. Senate Committee on Appropriations, 2012). Patient outcomes from advanced treatment of traumatic injuries on the battlefield that have resulted from this training will inform policy regarding what nurses need to know to provide this specialty care.

As with U.S. health care costs over the past decade, expenses for the MHS have also significantly increased, more than doubling from $19 billion dollars in 2001 to a projected budget of $49.4 billion in 2014, equivalent to approximately 9.5% of the entire DoD budget. Although reasons for this large increase are many, two in particular receive great attention from Congress. There currently exists a vast amount of duplication and redundancy within the current three service medical departments (Air Force, Army, and Navy). This includes personnel, processes, and equipment, which add to growing defense health care costs. Additionally, wartime requirements have led to increased expenditures. When military health care personnel are deployed, patient care is often shifted to civilian care, which is more expensive (Beasley, 2012). To be fiscally responsible, the DoD has completed a comprehensive analysis of military health care spending. Strategic planning is aimed at eliminating duplication and redundancy as well as controlling costs, while continuing to provide optimal care (Office of the Under Secretary of Defense, 2013). Since 2007, military nurses have taken the lead role in standardizing health care policies and procedures related to education, training, and research for the DoD (Murray, 2009; Murray & Chaffee, 2011). For example, instead of creating new simulation programs to meet training needs in the National Capital Region, nurses brought together the three military services and civilian academic and health care institutions to create a robust platform reducing duplication of services. This initiative met the directive set forward by the Deputy Secretary of Defense for the three branches of the military to partner on education and training initiatives to reduce defense health care costs (Murray, 2010).

Historically, the VHA has been underfunded. However, for 2014, the VHA requested and received $64 billion dollars to provide reliable and timely

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resources to support the delivery of accessible and high-quality medical services to veterans. This is a 4.5% increase over the 2012 budget and approximately 40% of the total Department of Veterans Affairs budget (Merlis, 2012). One reason for escalating costs is the financial outlay required to cover the increased number of veterans seeking care from the VHA as a result of physical and mental injuries to personnel who have been deployed multiple times in Iraq and Afghanistan. Funding will support acute hospital, rehabilitative, psychiatric, nursing home, noninstitutional extended state home domiciliary, and outpatient care. The budget also supports upgrading of treatment facilities as well as the purchase of equipment and supplies. In addition, the VHA is the United States’ largest provider of graduate medical and nursing education as well as a major contributor to medical research which is supported by the annual budget (U.S. Department of Veterans Affairs, 2013b; 2013c).

Like the MHS, the VHA is expected to provide exceptional care while controlling costs, and has implemented a number of performance measures aimed at continually monitoring the provision of high-quality care, access to care, revenue cycle improvement to improve efficiency and accuracy, as well as partnering with the MHS to improve collaboration and sharing of resources. In fact, for many years the VHA was considered an industry leader because of its safety and quality measures (U.S. Department of Veterans Affairs, 2013c).

Advanced Nursing Education and Career Progression

The MHS places great importance on advanced nursing education. During war, health care continues to evolve based on the nature of combat as well as the challenges posed by working in the austere environments characteristic of the battlefield (Spencer & Favand, 2006). Military nurses must possess the advanced practice specialty skills needed during conflict. Additionally, master’s degrees are required to be obtained before being promoted to more senior military ranks. Professional growth and development is continuously provided throughout a nurse’s career in the MHS by way of leadership experiences, on-the-job training, and continuing education. A variety of educational programs, including postgraduate opportunities, are available. Full funding, in addition to continuing to receive full salary and benefits, is provided for nurses earning advanced practice degrees as well as those pursuing doctoral studies. The armed services are committed to advancing military nursing science to optimize the health of military members and their families. Graduate education in civilian programs is available for selected promising nurse researchers. Additionally, to further advance the nursing research needs of the MHS, in 1992 Congress established the TriService Nursing Research Program (TSNRP), which is the only program funding and supporting rigorous scientific research in the field of military nursing (Duong et al., 2005).

TSNRP funds a wide range of studies to advance military nursing science. For example, in 2011 a pilot study was conducted to determine the sensitivity and specificity of small animal positron emission tomography-computed tomography (PET-CT) in identifying metabolic changes in muscle tissue surrounding simulated shrapnel injuries, and comparing this imaging with traditional x-ray images. Results showed the PET-CT to be more sensitive in identifying tissue changes. Military nurses now have a unique opportunity to educate patients and military health care providers, as well as to inform policy changes, about the possibility of early tissue changes around embedded shrapnel fragments and the use of PET-CT imaging as a possible surveillance tool. Another study supported by TSNRP in 2010 sought to understand how posttraumatic stress symptoms (PTSS) affect couple functioning in Army soldiers returning from combat. Findings included that almost 50% of couples had at least one person in the relationship with a high level of PTSS. Based on these results, development of interventions and policies designed to mitigate, or even prevent, negative outcomes such as divorce, violence, and suicide for military couples facing combat deployment are under way (TSNRP, 2013).

The VHA, like the MHS, also places great emphasis on the role of advanced practice nurses and currently employs approximately 5300 (4267 NPs, 533

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CNSs, and 500 CRNAs) (U.S. Department of Veterans Affairs Office of Nursing Services, 2010; United States Government Accountability Office, 2008) to deliver care. The VHA also recognizes the importance of providing educational benefits for nurses, thus permitting them to participate in graduate education. Additionally, VHA facilities provide some of the best platforms for clinical education and experience which many nurses use in their advanced studies (Caroselli, 2011). For example, VHA health care facilities provide a broad spectrum of primary, medical, surgical, behavioral health and rehabilitative care, and diagnostic services that serve as excellent clinical training sites. The VHA has also established the VHA Nursing Academy to address the growing national shortage of nurses. Although not a nursing school, the Academy establishes partnerships with academic institutions to expand the number of nursing faculty, enhance the professional and scholarly development of nurses, and increase student enrollment in nursing programs. For instance, advanced practice nurses and nurse researchers from the VHA serve as clinical instructors and faculty. The Academy provides excellent experiences for nurses and thus serves as a recruitment source. Following graduation, many nurses seek employment at VHA hospitals to focus on the health care needs of veterans (Caroselli, 2011; U.S. Department of Veterans Affairs, 2012).

Contemporary Policy Issues Involving MHS and VHA Nurses

Posttraumatic Stress Disorder

The problem of posttraumatic stress disorders in veterans has existed for centuries; however, the condition is attracting high levels of current attention caused by the conflicts in Iraq and Afghanistan and the disorder now impacts up to 22% of veterans (Johnson et al., 2013; Murray & Garbutt, 2012; Sabella, 2012). VHA and MHS nurses, along with their behavioral health counterparts, have collaboratively developed evidence-based guidelines on assessment and effective treatments which include multiple treatment modalities such as trauma-focused psychotherapies (e.g., exposure therapy), anxiety management, stress reduction, guided imagery, relaxation techniques, cognitive processing and behavioral therapy, and social support (Johnson et al., 2013; Murray & Garbutt, 2012; Murray & Smith, 2013; Sabella, 2012).

Current policies highlight requirements related to the timely assessment, treatment, and follow-up care of PTSD in both DoD and VHA clinical settings (U.S. Department of Veterans Affairs & Department of Defense, 2010). However, most military service members and veterans do not seek treatment for PTSD because of stigma, barriers to care, and negative perceptions associated with receiving mental health care (Hoge, 2011; Murray & Garbutt, 2012; U.S. Department of Veterans Affairs & Department of Defense, 2010). Policy issues requiring high priority include better understanding of the barriers to low mental health service use in the MHS and VHA (Hoge, 2011). Nurses are highly instrumental in understanding obstacles to care as well as working to develop and implement collaborative care models to increase outreach to veterans in need of mental health services.

Sexual Assault

Although the DoD and VHA continue to address military sexual trauma (MST; sexual assault or repeated, threatening sexual harassment that occurs during military service) and to describe what is being done to tackle this issue, many members of Congress believe there is an epidemic in the armed forces. It is estimated that 6.1% of women and 1.2% of men serving in the armed forces experienced and reported unwanted sexual contact in 2012. These numbers are believed to be much higher given that incidents go unreported as a result of fear of retaliation which could impact careers and the lack of trust that appropriate action will be taken against the offender (Johnson et al., 2013). Most experiences (67%) happened at work on military installations (Department of Defense, 2012). This is not a new issue for the military. For over two decades senior military officials and members of Congress have proposed recommendations to address sexual assault and harassment. Despite these efforts, the

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incidence of such events continues to increase annually. This creates substantial financial and emotional cost that affects several generations of veterans and lasts long after a victim leaves the military. At this point, the VHA picks up the costs associated with a variety of physical and mental health problems (primarily posttraumatic stress disorder and depression), which sexual assault and harassment can trigger.

In 2013, Congress required a response to this ongoing problem. NDAA 2013 mandated immediate policy changes to include investigation of all occurrences of sexual misconduct, requiring an independent review of all legal proceedings and investigations surrounding MST, and improving victim protections and reporting policies (U.S. Department of Defense, 2013). VHA mental health providers, including nurses, are developing and evaluating therapies specific to MST. Furthermore, nurses are using telehealth technology to reach out to veterans in remote areas of the country.

Suicide

Veteran suicide in the United States continues to remain an underreported epidemic and the most critical health issue facing the MHS and VHA. It is estimated that approximately one service veteran dies by suicide every hour (Murray & Smith, 2013). Veteran suicide rates have been reported to be as high as 20 per 100,000 people, or almost twice that of the United States in general (Murray & Smith, 2013; U.S. Department of Veterans Affairs, 2012). Several factors are associated with these alarming numbers. For example, many veterans suffer from comorbid mental health disorders such as PTSD, depression, impulsive behaviors, and substance abuse (Sher, Braquehais, & Casas, 2012). Suicide risk is also greater in veterans experiencing relationship problems, social isolation, difficulty reintegrating into the civilian community, and financial difficulties related to unemployment (Murray & Smith, 2013).

Efforts must be expanded to connect more veterans to the mental health resources needed to combat any suicidal tendencies. Concerns about confidentiality, stigma associated with mental illness, and limited availability of mental health services in some locations continue to be the major barriers to veterans seeking appropriate mental health care (Merlis, 2012). Another problem is delayed access to care. It is VHA policy that veterans seeking mental health care are seen within 14 days. The reality is that the wait for many is closer to 50 days on average before treatment is received. Although backlog has been identified as an issue, a greater problem is scheduling procedures not being followed. Instead of veterans receiving an appointment within 14 days, they are oftentimes given the next available appointment, which could be months away, placing a veteran’s well-being at risk (Office of the Inspector General, 2012).

The MHS and VHA continually strive to improve upon suicide prevention programs. Current priorities include a national suicide prevention hotline with free access to trained counselors 24 hours a day, 7 days a week, 365 days a year (Figure 39-2). Since 2007, response has been provided to more than 825,000 callers with more than 28,000 life-saving rescues. In 2009, the VHA initiated an anonymous on-line chat service. To date, this service has provided help to more than 94,000 individuals (U.S. Department of Veterans Affairs, 2013d). The hotline and online chat system are just two approaches within a more comprehensive plan developed by the VHA to prevent suicide but are not enough to tackle the problem since not all veterans are aware of the hotline, on-line chat, and other available mental health services (U.S. Department of Veterans Affairs, 2013d). VHA nurses are working to provide outreach programs to educate

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veterans and their families about the Veterans Crisis Line and online chat as well as collaborating with communities and partner groups nationwide (e.g., community-based organizations, Veteran Service Organizations, and local health care providers) to spread the word about the mental health services available through the VHA (Johnson et al., 2013; Mason & Schwartz, 2014).

Veterans Crisis Line.

Treatment plans for veterans who have suicidal thoughts and behaviors include somatic therapies (e.g., medications) as well as psychosocial and psychotherapies (e.g., cognitive behavioral processing). Equally important is addressing the spectrum of challenges confronting veterans. Although many are related to mental health, others include difficulties with reintegrating into family and community life as well as finding employment (Murray & Smith, 2013).

Access to Care

More recently, it has come to light that access to care for veterans is worse than previously thought. In May 2014, the Veterans Affairs (VA) Inspector General began to investigate patient wait times and scheduling practices on the basis of concerns that veterans were not receiving timely care. Preliminary findings showed that systemic patient safety issues and possible wrongful deaths occurred as a result of gross mismanagement of resources, unethical behavior, and possible criminal misconduct by VHA senior hospital leadership. Before the 2014 investigation, a 2013 U.S. Government Accountability Office (GAO) report determined that at least 50 veterans experienced delayed gastroenterology consultations for colon cancer, some of whom later died of the disease. Findings such as this provided evidence that delayed access to health care is associated with negative health outcomes (Chokshi, 2014), and these scheduling practices are not in compliance with VHA policy (U.S Department of Veteran Affairs Office of the Inspector General, 2014). Kizer and Jha (2014) noted that almost 20 years ago the VHA had to implement sweeping reforms to increase both quality and accountability. The reforms of the 1990s improved quality and increased access and efficiency (Kizer & Jha, 2014). The successes of the past reforms in the VHA provide clear evidence that the problems are fixable (Kizer & Jha, 2014) and new reforms are again needed to fix current challenges. One such attempt at reform is the VA Management Accountability Act of 2014, which has passed the U.S. House of Representatives and gives the Secretary of the VA greater authority to fire senior administrators. In addition, Senator Bernie Sanders (I-VT) along with John McCain (R-AZ) introduced a bipartisan comprehensive bill that supports veterans having access to community as well a federal health care providers. The bill also provides emergency funding for the VHA to hire more physicians, nurses, and other health care workers.

Post-Deployment Health-Related Needs

During World War II, the likelihood of surviving battlefield injuries was approximately 70%; during the Vietnam War survivability improved to 76%; and survival of service members wounded in the wars in Iraq and Afghanistan has increased to over 90%. Greater survivability is related in part to advances in medical care, improved protective gear (e.g., Kevlar vests), new medications (e.g., clotting agents), and significantly improved medical evacuation transport systems so that the wounded receive emergency surgeries within 30 to 90 minutes of injury. Despite these good survivability statistics, injured service members have significant physical, emotional, and cognitive injuries requiring attention for decades afterward (Manring et al., 2009; Tanielian & Jaycox, 2008).

Posttraumatic stress disorder, depression, and traumatic brain injury continue to be high-level policy interests for the MHS and VHA because these health-related issues often go unrecognized (Merlis, 2012). Additionally, a gap remains in the state of the science related to traumatic brain injury and the most effective way to address this pro­blem (Murray & Chaffee, 2011; Tanielian & Jaycox, 2008). Each of these conditions has wide-ranging and harmful consequences if untreated. Employment, family relationships, social functioning, and parenting are severely impacted. Additionally, recurring problems such as substance abuse,

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homelessness, and suicide can occur. These invisible wounds of war will continue to require high priority to ensure they are appropriately recognized. Effort is needed to ensure policies and programs are consistent across the military services, within the VHA, and in collaboration with the civilian sector if they are to realize care-seeking behaviors and result in improvements in the delivery of high quality care for veterans (Tanielian & Jaycox, 2008). Policy discussions at the national congressional level are essential to determine if the MHS and VHA have the capacity to address the needs of the veteran population and how non-VHA health care settings can help address the rapidly growing needs of America’s veterans (Johnson et al., 2013).

Additionally, the American Academy of Nursing has created an awareness campaign as another avenue to improve health care for veterans. Have You Ever Served? encourages all health care providers to identify veterans in their patient population to ensure they receive the appropriate type and level of care for military-related conditions (Collins, Wilmoth, & Schwartz, 2013). See Box 39-1 for more information on Have Your Ever Served?.

Box 39-1

Have You Ever Served?

byDiana J. Mason

Despite the crisis that occurred in the spring of 2014 over excessive wait times for veterans seeking care in the VHA system, and cover-ups by administrators at some VHA health care facilities (Veterans Health Administration, 2014), VHA clinicians are nonetheless experts in assessing and managing health conditions that arise from service-related exposures and injuries. These exposures vary by service period, location, and role the veteran played.

The 2014 crisis resulted in calls for increasing veterans’ access to care in the private sector. Only about one fourth of veterans receive their care in the VHA health system with the remainder either not accessing any care or getting it from the private sector. A 2011 survey of community mental health and primary care providers revealed that only about 44% ask their patients whether they are veterans (Kilpatrick et al., 2011). Linda Schwartz, PhD, RN, FAAN, U.S. Assistant Secretary of Veteran Affairs for Policy and Planning, has noted that veterans may present to clinicians in the private sector with symptoms that clinicians may not recognize as service-related. As a result, veterans can live in chronic pain or be misdiagnosed for years.

As part of First Lady Michelle Obama’s Joining Forces initiative ( www.whitehouse.gov/joiningforces ), the American Academy of Nursing developed an initiative to increase clinicians’ awareness of the importance of assessing every patient’s veteran status, including whether the patient is a child of a veteran, since some exposures during war can cause genetic changes for offspring and some families have been exposed to toxins on military bases. The initiative is called “Have You Ever Served in the Military?” and aims to have all clinicians ask patients, “Have you ever served? If so, when and where did you serve and what did you do?” In addition, the initiative aims to embed in the electronic health record an algorithm that begins with this question and then links the responses to potential exposures, symptoms, and health problems.

The initiative was endorsed by the National Association of State Directors for Veteran Affairs. More information about the initiative can be found at www.haveyoueverserved.com .