The Changing Faces of the Post-9/11 Wounded, Ill & Injured and Care Coordinate September 23, 2016 The Warrior-Family Roundtable (WFR) discussion was held September 23, 2016 at The Chicago School of Professional Psychology in Washington, D.C. The purpose of the WFRs is to expand on previous MOAA forums and efforts to improve the physical, psychological, and overall wellbeing of our warriors and their families. In partnership with Zeiders Enterprises, Inc., the Roundtables provide a valuable, informal and non-attribution venue for targeted and detailed discussions, idea exchange, collaboration, and problem solving. The Roundtable is a networking and discussion forum aimed at enhancing communication in the public and private-sector, offering key leaders or influencers an opportunity to generate new insights and leverage strengths and resources at addressing contemporary, cross-cutting and emergent issues. Summary MOAA and Zeiders Enterprises recognized the positive impact of the assembled group of community leaders on the warrior-family communities and thanked The Chicago School of Professional Psychology for their continued participation and hosting the group in their facility. The Rountable was the second of a three-part series this year on the Care Coordination efforts of the Departments of Defense (DoD) and Veterans Affairs (VA) for Wounded, Ill and Injured (WII) and their families and caregivers. This forum specifically focused on the Post-9/11 WII population how the population and needs have changed over time. Background The following details were provided in advance as background for framing the discussion: The wars in Iraq and Afghanistan have brought to the forefront new advances in battlefield medicine and new challenges in how we care and support those with combat and serviceconnected wounds, illnesses, injuries, and disabilities in unprecedented ways. The 15 years of war and conflict have resulted in a significant number of seriously WII. According to the Center for a New American Security (CNAS) Report, Passing the Baton: A Bipartisan 2016 Agenda for the Veteran and Military Community, November 2015 Report, more than 2.7 million service members have deployed since 9/11 as of July 2015: 52,351 individuals wounded in action 1,645 battle-injury major limb amputations Over 327,299 traumatic brain injuries (8,287 in the penetrating or severe category) many more unknown Hundreds of thousands of individuals with service-connected conditions prevalent conditions include: #1 musculoskeletal #2 mental health
#3 unspecified illnesses Presentation of long-term illnesses (deployment exposures, including gastrointestinal disorders, skin diseases, and respiratory) and latent issues (environmental exposures and catastrophic/late stage diseases and cancers). DoD-VA Care Coordination Panel DoD, VA, RAND Corporation, and CNAS subject-matter-experts led an interactive discussion with attendees on how the WII population and their needs have changed over time, how DoD and VA programs have changed to meet evolving needs, and, what are the unmet/emerging needs in care coordination today and projected over the next 2-5 years? Carrie Farmer, Ph.D., Senior Health Policy Analyst, RAND Corporation o General Research Information and Independent Assessment of VA Health Care 2015 Report (mandated in the Veterans Access, Choice and Accountability Act of 2014 [Choice Act]) Findings: Number of Veterans using VA health care has increased over time expected to continue to increase over the next five-years because of nearterm conflicts, but is expected to drop overall in future years by 19% due to overall deaths and military end-strength adjustments. Some studies show an increase in wait times for services questions exist around calculation and reporting of wait times Issues of cultural competency among community health care providers, indicating an impact on Veteran health outcomes and/or barriers to accessing care Issues with individuals not self-identifying as a the Veteran when seeking care Approximately 15% of Post-9/11 Veterans diagnosed with posttraumatic stress (PTS) o Change in allocation of resources will be required as Veteran population changes o Challenges with training providers on recognition of behavioral issues related to military service o 7,300 Veteran suicides per year/20 per day more research needed to determine the exact risk factors, triggers, and prevention options o Post-9/11 caregivers are 4 times more likely to be at risk for traumatic stress and depression related issues compared to caregivers of earlier conflicts o Big push in public and private partnerships to address issues and gaps in government programs Phillip Carter, Senior Fellow and Counsel, CNAS o Combat casualty totals much lower today due to medical advances on the battlefield 2
o 5,000 troops in Iraq no large scale combat operations o Not the same population of WII as 10 years ago somewhat the same volume of casualties today, but mostly due to training injuries, accidents, normal wear and tear of military life, and the aging process rather than operational tempo in theater o Government focus has been on economic, employment and education issues o Questions remain as to who owns the Veteran employment issue e.g., DoD, VA, Department of Labor? CAPT Brent Breining, USN, Navy Wounded Warrior-Safe Harbor Program o History 2006 National Defense Authorization Act (NDAA) Congress mandated the establishment of Service wounded warrior programs; 2008 NDAA required expansion on these programs 2005 Safe Harbor Program three staff members and 20 combat wounded warriors Today program grown over 20-fold to 75 staff members, serving over 2,600 seriously WII service members and 1,750 less seriously WII receiving assistance with their immediate needs o Unlike the Army and Marine Corps, due to the size of its population and relatively lower incidence of combat exposure, the Navy has employed a decentralized program for providing wounded warrior support, with enrolled Sailors and Coast Guardsmen remaining attached to their parent commands o Customized, individually tailored non-medical care support provided which includes a comprehensive recovery care plan that serves as a road map outlining recovery, rehabilitation and reintegration goals--also offers adaptive sports and reconditioning opportunities, pay and entitlements support, transition assistance, traumatic brain injury (TBI)/PTS support services, and more o Emerging trends and issues within the WII population Early 2014: ratio of illnesses to injuries was about 50/50 2016: illnesses outpace injuries at a ratio of 60/40 55% of enrolled illnesses are due to cancer and PTS diagnoses while 51% of injuries are due to TBIs and internal injuries. o Greater awareness of hidden wounds is critical; conservative estimates are that 10-20% of the over 2 million Iraq and Afghanistan combat Veterans are returning with symptoms of PTS; this equates to between 200-400K service members in need of care there simply are not enough clinical resources within the public and private sector to meet this demand o Events like the Bush Institute s Symposium on Hidden Wounds held in conjunction with the Invictus Games last May are key to creating awareness amongst policy makers and the general public o Public-private partnerships are the key to moving forward with wounded warrior recovery care; enduring funding continues to be a challenge as we move away from a period of sustained combat we are challenged to message to senior leadership the requirement for enduring sustainment of these programs 3
o Since 2013, this program has grown at an average rate of 25% per year due to greater awareness of available services within the Fleet o Suggestion: Enacting policy that allows Wounded Warrior Programs to discuss needs with NGOs without crossing the line into solicitation will be a good start to creating better synergy amongst these programs. While Congress and the Executive Branch have challenged our programs to work more closely with our NGO partners in delivering support to our wounded warriors, the current ethics rules are arcane and restrict our ability to fully operate in this maneuver space. Additionally, the Secretary of Defense DOD-Memorandum needs to be broadened to include all wounded warriors, not just combat related. This would affect our E-7 and above population. 80% of the Navy Wounded Warrior population is enrolled due to serious illnesses and injuries. While not quite as large, the Army and Marine Corps are experiencing a similar demographic shift as we get farther away from the wars. SMSgt Cassie Fennern, USAF, Senior Enlisted Advisor, Air Force Warrior & Survivor Care Program The Air Force Wounded Warrior (AFW2) provides personalized care, services and advocacy to seriously or very seriously WII Total Force recovering Airmen and their Caregivers and families by focusing on specific personal and family needs throughout the recovery process and beyond. Support and care is provided to all recovering Airmen, both combat and non-combat. o The AF strives to maintain Airmen in their home units during recovery and rehabilitation and believes in working on holistic Recovery Coordination this is accomplished in part by conducting various regional CARE Events throughout the year, which focuses on Caregiver Support; Adaptive Sports; Recovering Airman Mentorship Program (RAMP); and Employment and Career Readiness o Recovery Care Coordinators (RCC) and Non-Medical Care Managers (NMCM) provide well-coordinated and personalized support to recovering Airmen and their Caregivers and families by advocating for the Airman to ensure accessibility and minimize delays and gaps in medical and non-medical service the RCCs and NMCMs use a 7 Phase Continuum of Care that runs from the initial identification through recovery and rehabilitation to reintegration back into active duty or transition to retirement or separation o RCCs and Non-Medical Care Managers (NMCM) provide well- coordinated and personalized support to recovering Airmen and their Caregivers and families by advocating for the Airman to ensure accessibility and minimize delays and gaps in medical and non-medical service the RCCs and NMCMs use a 7 Phase Continuum of Care that runs from the initial identification through recovery and rehabilitation to reintegration back into active duty or transition to retirement or separation 4
o Current State of the Program: Over 100 new Airmen enrolled per month. Population as of 1 Sep 16: 6,310 (1,511 AD / 4,799 Veterans) 5,059 Regular (80%) 772 Guard (12%) 479 Reserve (8%) AFW2 Case Category 1,621 Illnesses 3,323 Psychological wounds (2,606 PTS) 1,366 Physical wounds (includes TBI) Combat vs. Non-Combat Enrollment Combat Related: 34% Non-Combat Related: 66% o Ongoing efforts of the program: Provide additional caregiver support Obtain a better understanding/identification of illnesses caused by exposures during deployment Expanding services to help strengthen the transition from the AF to VA Identifying and assisting those suffering from invisible wounds (i.e., PTS, depression, TBI, etc.) earlier in the process Accurately project/manage the growth in Veterans that has occurred and will occur in the future Paul Williamson, Command Advisor, USMC Wounded Warrior Regiment The Wounded Warrior Regiment was established in 2007 by the 34 th Commandant to serve as the Marine Corps single command responsible for executing our service s Recovery Care Coordination efforts. The WWR provides and facilitates non-medical care to combat and non-combat wounded, ill, and injured Marines, Sailors in direct support of Marines, and their families. Marines requiring complex care coordination are joined to a WWR element; those with fewer needs may remain with their parent units while receiving external support from WWR in the form of a RCC, in accordance with Department of Defense Instruction 1300.27. o As of September 2016, the WWR supports a total of 933 Marines through assignment to the Regiment and/or an RCC. 97% of those receiving services will transition out of service o Recent and projected overseas operations are resulting in fewer combat casualties the ever present non-combat injuries and illnesses, across the Marine Corps, will likely remain stable based on historical information currently, approximately 93 percent of the WWR s Marines are ill / injured outside a combat zone; four percent are combat wounded; and three percent are ill/injured in a combat zone, which includes post-traumatic stress (PTS) and traumatic brain injury (TBI) 5
o Marines preparing to transition to civilian life receive follow-on support from WWR for a minimum of 90 days through support coordinators, field support representatives, or call center representatives Post-service support is most often initiated through the Wounded Warrior Call Center The WWR also coordinates closely with VA designated Lead Coordinators to ensure a warm hand-off during transition of a recovering Marine with complex care needs from DoD to VA services Due to the fact that Marines joined to a Regiment element have been determined to be complex care cases through a referral board, their assigned Marine Corps RCC is concurrently designated as their Lead Coordinator Despite some differences in how each entity assesses the support a Marine is entitled to receive based on his or her current medical status, the VA will continue active involvement for 90 days post end of service when requested by the WWR in order to ensure successful transition and subsequently conduct a needs assessment for VA support o On an average ratio of 20:1, our 44 Recovery Care Coordinators (RCCs) work with WII Marines and their families to develop and execute their Comprehensive Recovery Plans RCCs are part of the Marine s recovery team working closely with the Marine s command and medical team to optimize recovery; currently, approximately 889 WII Marines are receiving RCC support o VA Federal Recovery Coordinators (FRCs) are VA employees embedded at the WWR HQ on a non-reimbursable basis. The FRC is fully invested in our recovery team efforts and helps ensure Marines smooth transition to VA o WWR Transition Specialists are available to WII Marines and families to enhance community reintegration by identifying employers and education opportunities to help ensure they are competitive in the job market o Historically, approximately 1 1.5% of the total Marine force end-strength is referred into the Department of the Navy Disability Evaluation System (DES) for duty related illnesses and injuries and will continue to require WWR resources and services of the 2,484 Marines currently enrolled in the DES process 535 are receiving a high level of recovery support through the WWR; however, WWR monitors the processing of all Marine IDES cases o WWR, through the District Injured Support Coordinators and Wounded Warrior Call Center, support wounded, ill or injured Marines after separation from service these capabilities allow the WWR to keep faith with our Marines and offer continuing assistance through transition to Veteran status o Increasingly important is the WWR s continued facilitation between the Marine Corps and Veterans Affairs in order to ensure successful transition of individual Marines as well as ongoing progress in service coordination o Focus of the program has shifted beyond strict medical recovery to body, mind, spirit and family 6
Dr. Jack Smith, Director, Defense Health Services Policy & Oversight The ongoing collaboration between VA and DoD on the Interagency Care Coordination Committee (IC3), which was briefed in more detail at the April Warrior Family Roundtable, continues to progress. The focus of the IC3 effort is to provide extra assistance with coordination of care, benefits and services throughout the course of recovery for those Service members and Veterans (SM/Vs) with the most serious illnesses and injuries or those with less serious medical conditions who have other factors that make their recoveries particularly challenging or complex. The primary tool for this patient-centered, needs based model is use of the Lead Coordinator model for Complex Care Coordination, features of which include a care coordination checklist, use of a comprehensive plan for recovery, and guidelines for "warm hand-offs" during care transitions. o Interagency Disability Evaluation System (IDES) has a population of approximately 20,000 with a fairly stable balance of ill or injured Service members entering and exiting the evaluation process o Enrollment in Service Wounded Warrior Programs (WWP) is approximately 12,000 Service members across all Services o Our target population for IC3 care represents a sub-set of the IDES and WWP numbers (in addition to Veterans being tracked and receiving case management from the VA) DoD and VA are working together to better identify, track and assist these SM/Vs and their families or caregivers o Significant progress has been made in getting agencies to speak the same language to make warm hand-offs, and to focus efforts on those the most highly complex needs in order to mobilize required services o Interagency communities of practice are taking place which are allowing outreach to capabilities beyond those resident at a particular location Karen Malebranche, Executive Director, VA Office of Interagency Health Affairs o Advised that VA wait times for care were now averaging 2 weeks o Cultural competency courses for practitioners have been implemented o Mobile centers Increasing Veteran Center and allowing family access is on the horizon o Sharing with DOD is occurring at increasing levels o Suicide office has opened to work on identification and prevention and DOD also has suicide prevention office o Links to VA reports referenced: Reports on Veterans' Health Data: landing page for all reports http://www.publichealth.va.gov/epidemiology/reports/index.asp VA Health Care Utilization by Recent Veterans http://www.publichealth.va.gov/epidemiology/reports/oefoifond/healthcare-utilization/index.asp 7
Comparison data: Veteran, GW and OEFOIF http://www.publichealth.va.gov/docs/epidemiology/pdsr-vol1-no1.pdf Brainstorming Breakout Session Following the panel presentations, the participants were separated into two groups for a brainstorming session, centering on the following topic. Each group reported on their discussion. What should the New Administration/Congress (Government) and NGOs focus on over the next 2-5 years to address the short and long-term unmet/emerging care coordination needs of our changing WII population? Breakout Group 1: What should Government focus on? (List of short-long-term needs e.g., research related to TBI, PTS, sexual assault, and cancers; vetting of NGOs) 1. DOD-VA need comprehensive research on PTS. a. What is working in regards to treatment options? b. Longitudinal focus: Diagnosis Recovery, uncover trigger event and emergence 2. Do not lump PTS and TBI together as one and the same conditions may co-exist but are unique and separate conditions 3. Conduct a research study similar to the National Vietnam Study for current war Veteran population 4. Develop and adopt a common language in DoD-VA WII Programs a. Office Program Titles b. Benefits and Service Programs c. Resonates with NGOs and outside organizations 5. Provide additional and continued support to care coordination/ support, including receiving services from VA and community 6. DoD-VA Caregiver Support a. Synchronize Special Compensation for Assistance with Activities of Daily Living (SCAADL) and VA Caregiver Support Program Merge these 2 programs into 1 program Expand to veterans of all eras b. Expand respite care to address changing patient/caregiver needs over time 7. Fully implement health records interoperability (Electronic Health Record EHR). Military VACommercial 8. Expand long-term health care and support services 9. Establish short/long-term integrated network of health care 10. Ease restriction of DOD-VA collaboration, partnership and gifting with non-profit sector 11. Address recruits with pre-existing behavioral health issues 12. Include Veterans, family members and survivors in the national defense budget 13. Review effectiveness of Temporary Disability Retirement List (TDRL) and Integrated Disability Evaluation System (IDES) 14. Evaluate and mitigate disruption among various federal medical benefits (e.g., TRICARE, VA, Medicare, etc.,), integrating systems where possible 8
Breakout Group 2: What should NGOs focus on? (List of short-long-term needs e.g., legal and financial assistance for end of life decision planning; child care services) 1. NGOs should use their platforms by demanding/pushing government to research the effects of exposure (coordinated effort) e.g. CDC, and other agencies that may be collecting information to combine and manage diseases form wars (Gulf War, Burn Pits and other exposure issues) 2. Communication/outreach to educate to increase government and the public awareness of the WII population/needs NGOs have ability to provide targeted information on topics with captive audiences and dedicated forums for communications 3. NGOs need to collaborate with each other more at a national level the competitive nature of donor dollars and NGOs doing everything for everyone dilutes resources and focus a. Emphasize quality of and refer WII to NGOs where their strengths are best suited b. Formulate policy at national level and implement at local level 4. Inform and educate at the national level on what services are provided NGOs and what gaps exist 5. Establish regional NGO representatives within VBA/VHA District Offices NGOS have been kept at arm s length because government has been taught to remain vigilant to deceptive practices and predatory organizations 6. Create a dedicate online forum for NGO s to provide updates to the National Resource Directory (NRD) a. Address ownership/maintenance issues with the directory b. Improve navigation/user capabilities 7. Establish centralized/uniform Memorandum of Understanding/Agreements (MOU/MOA) process/format with government agencies multiple processes/formats in place; development waste time at local level and national level and across agencies DoD and VA should be able to reference master MOU/MOA 8. NGOs are able to respond more quickly to changing demands and real-time needs of the aging Veteran population (long-term care, health concerns, utility bills, etc.). 9. Combine federal, state and local efforts many states offer Veteran programs at differing levels and NGOs are unaware of what is available; these programs could be adjuncts to the NGO offerings by work together to streamline and maximize efforts and resources 10. Focus on upcoming issues with Veterans 65 or older 11. Keep resource lists current The Roundtable will utilize the results of the brainstorming session in the final meeting on Thursday, December 8, 2016 to create a Top 10 Needs for WII/Families Information Paper. MOAA and Zeiders express our thanks to The Chicago School of Professional Psychology and to an enthusiastic and engaged audience. The WFR adjourned at 12:00. 9
Participant List Name Email Address Organization Title Dorian Anderson danderson@zeiders.com Zeiders Enterprises Director, Corporate Development Lauren Augustine lauren@iava.org IAVA Senior Legislative Associate Meredith Beck moseleymer@hotmail.com Consultant CAPT Brent Breining brent.breining@navy.mil Navy Wounded Warrior- Director Safe Harbor Megan Bunce mbunce@americaswarrior partnership.org America's Warrior Partnership Director, Government and Community Affairs Rene' Campos renec@moaa.org MOAA Director, Government Relations Phillip Carter pcarter@cnas.org Center for a New American Senior Fellow and Counsel Security Elizabeth Chisolm echisolm@qolfoundation.org Quality of Life Foundation Executive Director Jennifer Christner jchristner@legion.org American Legion Assistant Director Lynda Davis lynda.davis@taps.org TAPS Executive Vice President Brian Edelman bedelman@vva.org Vietnam Veterans of America Deputy Director for Policy and Government Affairs Dr. Carrie Farmer cfarmer@rand.org RAND Corporation Senior Health Policy Analyst SMSgt Cassie Fennern cassie.d.fennern.mil@mail.mil Air Force Warrior & Survivor Senior Enlisted Advisor Care Program Terry Fullerton terry.d.fullerton@healthnet. com MHN/ HealthNet Director, Implementation and Transition Management Paul Grugin pgrugin@hqafsa.org AFSA Deputy Director of Government Relations Amber Haf amber.haf@va.gov VA Clinical Program Analyst Ginger Hayes vhayes@zeiders.com Zeiders Enterprises Marketing Manager Chelsea Hilton chelsea@codeofsupport.org Code of Support Foundation Program Director, Case Coordination Meg Kabat margaret.kabat@va.gov VHA Caregiver Support Deputy Director Ryan Kules rkules@woundedwarriorproje Wounded Warrior Project Combat Stress Recovery Director ct.org Jennifer Legler jennifer.legler@va.gov VHA Director, VA/DOD Interagency Liaison Office Karen Malebranche karen.malebranche@va.gov VHA Executive Director, Interagency Health Affairs Kathleen Moakler kathy.moakler@taps.org TAPS Director, External Relations and Policy Analysis Simmone Quesnell simmone@codeofsupport.org Code of Support Foundation Program Director Paul Richardson prichardson@zeiders.com Zeiders Enterprises Senior Vice President for Contract Operations Andrea Sawyer andrea_sawyer@comcast.net Caregiver Dr. Jack Smith jack.w.smith2.civ@mail.mil OSD Health Affairs Director, Health Services Policy & Oversight Steve Strobridge steves@moaa.org MOAA Vice President, Government Relations Meggan Thomas mthomas@vfw.org Veterans of Foreign Wars of the U.S. Veterans Casework Consultant, Veterans Health Policy Carol Weese carol.weese@va.gov Department of Veterans Affairs Director, Federal Recovery Coordination Program Paul Williamson paul.williamson1@usmc.mil USMC Wounded Warrior Regiment Command Advisor 10