Previous Rural Monitor stories on rural veterans:
In its Spring 2007 issue, the Rural Monitor looked at how veterans from recent wars were sometimes having difficulty in finding treatment for PTSD and TBI in its story, Rural Vets Return Home to Face New Battles.
Another story in that issue, War Has Big Impact in Rural Areas, examined how the Iraq and Afghanistan wars were sometimes draining health care personnel from rural areas as they were called up to fight.
Veterans are one of the populations being targeted by the United States Interagency Council on Homelessness (USICH), which aims to create a national partnership at every level of government and with the private sector to reduce and end homelessness in the nation. The Council estimates that there are more than 70,000 veterans experiencing homelessness on any given night in the United States.
For more information on the regional rural health resource centers operated by the Veterans Health Administration Office of Rural Health (ORH), see the ORH Contacts page
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For a list of publications about rural veterans, see the ORH Publications page
What is PTSD?
The VA defines Posttraumatic Stress Disorder (PTSD) as “an anxiety disorder that can occur after you have been through a traumatic event. A traumatic event is something horrible and scary that you see or that happens to you.”
Statistics for PTSD and post-combat depression among veterans are not as firm as those for TBI because PTSD often has no immediate and visible symptoms and not all veterans with PTSD will seek help. Many soldiers experience varying degrees of trauma, but most of them will not develop long-term PTSD. Estimates for PTSD (and depression) among veterans of Iraq and Afghanistan are estimated to around 20 percent. VA data show that from 2002 to 2009, of the veterans from Iraq and Afghanistan eligible for VA care who came in for VA services, 48 percent were diagnosed with a mental health problem.
What is TBI?
The VA defines Traumatic Brain Injury (TBI) as something that “happens when something outside the body hits the head with significant force” such as when “a head hits a windshield during a car accident,” “a piece of shrapnel enters the brain,” or during an explosion of an improvised explosive device (IED).” Individuals who sustain a TBI may experience a variety of effects, such as an inability to concentrate, an alteration of the senses (hearing, vision, smell, taste, and touch), difficulty speaking, and emotional and behavioral changes. Whether the TBI is mild, moderate, or severe, persistent symptoms can have a profound impact on the injured survivor and those who serve as caregivers.
According to the Defense and Veterans Brain Injury Center (DVBIC), more than 200,000 veterans who have served since 2000 have suffered from TBI, with more than 44,000 of those cases labeled moderate to severe.
An estimated 43,000 soldiers left Iraq by the end of last year. As they find their way home, many will return to rural areas—an estimated 39 percent of veterans who served in Iraq and Afghanistan are from rural areas, and about 41 percent of veterans enrolled with the Veterans Health Administration (VHA) live in rural or highly rural areas of the country, according to the VHA Office of Rural Health.
Unfortunately, the average rural veteran in the United States currently travels 63 miles for care. That distance means that many will go without the care they need, or will be able to seek it only sporadically.
In this issue we look at programs that serve rural veterans in their communities, providing veteran housing and care for veterans with PTSD and TBI.
Services for Rural Veterans
Going Home:
Programs Create New Housing Options for Rural Veterans
by Candi Helseth
Transitional housing took Desert Storm veteran Manny Alvarado, 44, off the streets and returned him to productivity. Medical foster care gave World War II veteran Rex McMahill, 88, a way out of spending the remainder of his life in a nursing home. Both programs are among various housing options supported by the Department of Veterans Affairs (VA) to help veterans of all ages live as independently as possible.
Alvarado participated in the North Coast Veterans Resource Center (NCVRC) transitional living program in Eureka, Calif., as he climbed his way out of the pit that had become his life. Since 1998, NCVRC has helped homeless, unemployed or underemployed veterans become gainfully employed and establish permanent housing. The veterans, who live in NCVRC’s large, comfortably furnished Victorian Eureka House, are provided the basic physical essentials for daily living and given intensive case management support to find and get a job.
McMahill lived with his wife until she could no longer care for him. His advancing dementia made it unsafe for him to remain in their home. Medical Foster Homes (MFHs) provide a homelike option for veterans with major physical or mental disabilities who are unable to live independently. MFH care includes room and board, 24-hour supervision, medication management and assistance with daily tasks and personal care in a private home where caregivers are typically also the homeowners.
Medical Foster Homes Offers Family Setting
Rex McMahill, a WWII veteran, enjoys sitting on the deck of his Medical Foster Home, run by Bill Olson and his wife, Marilyn, out of their own home.
McMahill can still recall details about his Navy service during World War II, such as not seeing land for 23 months, but may not remember what happened earlier that same day. In September 2011, he moved into a MFH in Cambridge, Iowa, a small town close enough to his previous home that his wife and son can visit regularly. Homeowners Scott and Marilyn Olson oversee McMahill’s needs.
“I’m happy here,” McMahill says. “They get me up in the morning, make me breakfast, have things to do that I can help with and they are careful not to let me do something I shouldn’t. They’re just like family, awfully good to me.”
The Olson home is one of nine MFHs under the VA Central Iowa Healthcare System, according to Jan O’Briant, MFH coordinator. While the VA has long provided placement for veterans with medical needs through its Community Residential Care (CRC) program begun in the 1950s, MFHs are a more recent development. Central Iowa’s first MFH opened in 2009; the VA Black Hills Health Care System in South Dakota is in the process of opening its first two MFHs.
One of the program’s strongest components is the VA Home Based Primary Care (HBPC) team that is part of every MFH, said Michelle Hough, Black Hills MFH coordinator. The team includes a variety of medical providers that provide primary care in the home, improving consistency of care and reducing health care-related travel for the veteran.
Rex McMahill enjoys playing checkers at the Olsons' dining room table.
“Most vets in these homes have major diagnoses—chronic diseases like diabetes or heart disease and mental health issues like PTSD and dementia,” Hough said. “The majority of them are on 12 or more medications. It’s very important they get consistent care.”
Marilyn Olson says they have found new purpose in the home that seemed too big after all their children left. As caregivers, the Olsons receive ongoing training and their home is regularly inspected. VA limits MFHs to having no more than three veterans at a time.
“We’ve been very blessed to get to know these World War II veterans and their families,” Marilyn commented. “It’s just amazing how much we get back out of it.”
The Black Hills and Central Iowa Health Care System services are part of the VA Midwest Health Care Network (or, Veterans Integrated Service Network 23), which serves more than 400,000 veterans in Iowa, Minnesota, Nebraska, North Dakota, South Dakota and portions of Illinois, Kansas, Missouri, Wisconsin and Wyoming.
Transitional Housing Gets Vets Back to Work
On the other end of the housing spectrum is transitional housing, which offers veterans temporary shelter with the goal of teaching them to live on their own. Last February NCVRC expanded the Eureka House to include 34 beds for male and female veterans. NCVRC Site Director Rob Amerman said the veteran population is relatively high in their rural area, and the recessive economy has contributed to increasing numbers of unemployed or underemployed veterans.
The Eureka House in Eureka, Calif., offers treatment and transitional housing for veterans who have nowhere else to go.
NCVRC’s three-step program begins with assessing and referring for treatment those residents whose addictions or mental health problems contribute to their inability to support themselves. NCVRC provides treatment support in cooperation with local mental health and addiction agencies. Residents commit to staying clean and sober and submit to random Breathalyzer and urinalysis tests.
Alvarado is grateful that NCVRC gave him a second chance. He relapsed following the death of two family members and has been sober again for two years.
“I used alcohol to chase away the bad dreams I had from my days in the service and the loss of my brother,” he said. “But they have helped me learn to deal with my loss and grief in better ways than going to the bottle. Now I’m helping other veterans and I understand where they’ve been.”
Alvarado is an NCVRC employee now, working with residents to help them with issues such as anger management, interpersonal skills, relationship building and relapse prevention. As veterans resolve their personal battles, they move through program steps that include job-specific training such as resumé writing and interviewing skills, then going to job interviews, and finally, getting a job and saving money. They can stay at the Eureka House up to two years, and must save 50 percent of their income toward permanent housing expenses.
“We offer a safe place to rest their head, take hunger off their minds with three good meals a day and teach them how to get a job,” Alvarado said. “You start seeing the pride coming back in their step. When they graduate, they want to come back and support other veterans through their process. We know that supporting each other makes all of us stronger.”
The Department of Veterans Affairs (VA), the Emergency Housing and Assistance Program (EHAP), and Community Development Block Grants from the State of California Department of Housing and Community Development funded the Eureka House expansion. NCVRC is a division of the nonprofit Vietnam Veterans of California (VVC), which has five regions in northern California.
Last fall, the Department of Veterans Affairs' Supportive Services for Veterans and Families (SSVF) awarded VVC a $1 million grant that is assisting approximately 400 veteran families in northern California. Services include temporary financial assistance for expenses such as rent, utilities, moving, transportation, childcare and emergency supplies. Amerman said NCVRC also received a grant from SSVF to provide case management and financial assistance to stabilize families facing eviction and help homeless veterans and their families get into rental housing.
Additional Programs Provide Housing Support
Since 2009, VA and HUD have worked with more than 4,000 community agencies to successfully house 33,597 veterans in permanent, supportive housing with case management and health care access. Through SSVF, a homeless-prevention and rapid re-housing program, $100 million in housing-related grants is available in fiscal year 2012 to community agencies throughout the country.
“When we went into boot camp, asking for help was a sign of weakness,” Alvarado said. “We were trained to handle our own business, to be self-reliant. When vets come home, we don’t feel understood because people can’t really understand what combat is like. Now I tell the vets I work with, ‘You soldiered up for your country so you might as well veteran up for yourself.’ The more vets we can help get on their own two feet, the better off they are and all of us are. No veteran should be homeless.”
Co-Located Clinics Bring Improved Care for Veterans in New Mexico
by Candi Helseth
In rural areas where resilience and independence are admirable qualities and everyone knows everyone’s business, veterans with mental health issues resist seeking treatment. One solution is to co-locate mental health and primary care services, which, according to a 2010 study from the Milbank Memorial Fund, can be more effective because “the location is familiar and nonstigmatizing for patients.”
The VA's Clovis Community Based Outpatient Clinic in Clovis, NM, realized that advantage after it co-located its primary care and mental health services under one roof in 2003. The Clovis VA Clinic, which serves eight New Mexico and five West Texas counties, developed a treatment model that encourages collaboration and integration of services between psychiatry and primary medical care.
In addition to reduced stigma, co-location has resulted in more efficient coordination of care among providers and improved convenience for veterans, said Richard Dane Holt, a clinic therapist. Veterans can coordinate appointments, which requires less travel in an area where driving distances alone may require four to five hours out of the day.
“When mental health concerns are of an urgent nature, the patient is seen the same day,” Holt said. “Non-urgent cases are usually seen within a week.”
Stigma is reduced because veterans don’t have to enter a facility marked as a psychiatric or mental health unit. Primary care providers (PCP) quietly refer patients for mental health services in the same building. Once a veteran reaches a moderate level of stability under the care of a behavioral health professional, the PCP resumes care coordination and ongoing treatment. Mental health providers are immediately available for consultation as needed.
Post traumatic stress disorder (PTSD), depression, anxiety and substance abuse disorders have been the most common mental health diagnoses for veterans, Holt said. Using CPT (cognitive processing therapy) techniques, Holt has also successfully treated PTSD in veterans that experienced military sexual trauma, a term the Department of Veterans Affairs uses to refer to sexual assault or repeated, threatening sexual harassment that occurred while a veteran was in the military. Since Holt began using CPT in 2007, 40 veterans who were treated all reported reduced symptoms.
Services for Rural Veterans
Healing Invisible Wounds: Programs Help Rural Vets with PTSD and Depression
by Candi Helseth
By 2008, nearly 20 percent of military service members nationwide had returned from Iraq and Afghanistan reporting symptoms of PTSD (post traumatic stress disorder) or major depression, according to the report, Invisible Wounds of War. Yet, only slightly more than 50 percent have sought treatment.
Many of these veterans are returning to rural areas where health care resources are limited or even non-existent, requiring them to travel great distances for care.
“It is a true loss to society when the combat veteran is not transitioned and welcomed back home after the battle is done,” said Navy veteran Kevin Williams, a peer specialist with the Virginia Wounded Warrior Program (VWWP). “I’ve encountered a lot of veterans, and they all want the same things when they come home: a job, health care and a safe place to live, and the compensation and benefits of service that they were promised.”
In January 2011, President Barack Obama pledged the support of the federal government for increased behavioral health care services through prevention-based alternatives and integration of community-based services through the Strengthening Our Military Families initiative.
Also in 2011, VA Secretary Eric K. Shinseki participated in a Listening and Walking Tour, visiting veterans in North Dakota, Montana, and Alaska. As part of the initiative, the VA pledged to expand outreach clinics, Vet Centers, and mobile Vet Centers in order to reach more rural veterans, in addition to the $500 million it had given the VA Office of Rural Health (ORH), to fund more than 500 projects.
State Programs Reach Rural Areas in Virginia and Montana
Members of the Together for Veterans support group, sponsored by the Virginia Wounded Warrior program, meet together twice a month for mutual support and to learn about VA benefits and post-combat coping strategies. The group is open to veterans from any era.
In southwest Virginia, veterans seeking assistance at a VA hospital are likely to drive at least two hours over mountainous roads. With 25 HRSA rural-designated counties and a population density of only 76 persons per square mile, lack of health care access is a major barrier. After securing a three-year, $300,000 per year Health Resources and Services Administration (HRSA) Flex Rural Veterans Health Access Program (RVHAP) grant, VWWP Region 3 hired additional staff to coordinate provision of clinical mental health and Traumatic Brain Injury (TBI) services in the local communities. Grant funding also helps provide care coordination to VA facilities when local professionals refer veterans outside the community for medical care.
“The grant has really helped us put more staff into our local communities where we’re not blessed with some of the resources available in bigger areas,” Region 3 Director Matthew Wade said.
“Our resource specialists work one-on-one with vets to identify what resources they can access in our region. If veterans need resources outside the community, we work with other providers, such as bus companies, to arrange transportation.”
All five VWWP regions focus on community-based care, providing an array of services such as mental health screenings, referrals for PTSD and TBI, individual case management and care coordination, substance abuse identification and treatment, peer and family support groups, mental health community education and linkage to VA benefits. The statewide web site also provides planned interactions for veterans to connect and support one another.
Regions have individual autonomy, developing programs specific to needs in their area. Examples of services that vary by region include Equestrian therapy, couple’s retreat weekends to rebuild marriages, and group social activities such as gardening, hunting and social outings.
Coordinated by the Department of Veterans Services, VWWP is a statewide program approved for funding in 2008 by the Virginia General Assembly. VWWP prioritizes assessment and treatment for combat stress related issues and TBI through community-based partnerships and services for veterans and active members of the Virginia National Guard and Reserves. Family support, employment and housing are also among program components.
“The beauty of bringing these services into the local community and working with the community service boards (behavioral health providers) is that these are the clinical treatment programs for people with behavioral health needs,” VWWP Special Projects Coordinator Martha Mead said. “So they are likely to hear about or recognize issues these veterans may be having when they are back in their communities.”
Mead works from the statewide office, which appropriates state funding to the regions and oversees regional activities. In fiscal year 2011, VWWP connected 3,617 Virginia veterans and families to direct behavioral health services. VWWP staff also provided public education and community outreach at 615 locations, reaching more than 20,000 Virginians, including interactions with 6,550 military personnel and families.
Williams estimates it takes VWWP 12 to 18 months to help traumatized veterans make a successful transition back home. “Our program is really about taking the time to listen to the vet and provide the road map and support tools to jump start them along,” he said.
In Montana where a three-year, $300,000 per year RVHAP grant went into effect in October 2010, the “Increasing Service to Montana’s Veterans through Training, Team Building and Technology” program has already achieved several successes. Enrollment for veteran’s assistance has increased to more than 40 percent compared to nationwide statistics in the 30 to 35 percent range. A social media campaign specific to suicide prevention reached 21,000 vets. More than 3,000 requested information and assistance. Active partnerships have been established between the various military branches, the Department of Health and community health providers.
The grant targets 15 counties where Indian reservations account for nearly one-third of the land and the overall population density of veterans is double the national average, according to Project Manager Deb Matteucci. Project goals are three-pronged: training, team building and technology placement.
Training engages a variety of groups. For instance, law enforcement and/or rural emergency medical service units typically are the first responders to emergency calls there, Matteucci said. These providers are being taught to recognize combat-related symptoms and, when appropriate, refer veterans to VA assistance rather than placement in the law enforcement system. RVHAP grant funds are also bringing together entities such as the Montana statewide suicide prevention program, Veterans Affairs, Critical Access Hospitals (CAHs) and community mental health providers in partnerships to collaborate care and provide treatment closest to the veteran's home.
“We only have one VA hospital in the state so it’s important that veterans can be treated in their home communities,” Matteucci said. “Training has been our first priority. Rural providers need education to help them recognize and treat combat-related symptoms, which can be very different from the usual crises in these remote areas.”
While Montana is successfully using telehealth for medical treatment in several disciplines, infrastructure is limited and unavailable in many small rural communities, said Deb Matteucci., Project Manager for a Montana veterans program. Future plans, Matteucci said, call for CAHs in the grant region to become the hub for community resources and access to telemedicine support to the VA and major state medical centers.
Indiana (see Telepsychiatry Fills Gaps in PTSD Care, Virginia and Montana are among several states that have implemented programs to improve health care access and services for rural veterans. However, the Veterans Health Administration Office of Rural Health (ORH) 2012-2014 Strategic Plan states that 15 percent of soldiers returning from Operation Enduring Freedom and Operation Iraqi Freedom are estimated to have at least one service-connected disability and research demonstrates that rural veterans with mental health needs do not receive care comparable to urban veterans. Apparently, much still remains to be done to assure that veterans who proudly served their country are, in turn, being treated for the mental and physical wounds they incurred in the process.
Services for Rural Veterans
Telepsychiatry Fills Gaps in PTSD Care
by Candi Helseth
Telehealth reaches veterans unlikely to get help anywhere else, said Dr. Jay Shore, a psychiatrist with the VA Office of Rural Health Veterans Rural Health Resource Center. For the last 10 years, Dr. Shore and his team have been using telemedicine to treat PTSD in American Indian veterans living in remote areas on reservations in the Midwest.
Through regional VA partnerships and the use of live interactive videoconferencing, the treatment team works from the VA Denver office. Veterans travel to the nearest reservation clinic where a VA tribal outreach worker (TOW) coordinates the videoconferencing session.
“Native Americans serve at the highest rate per capita of any ethnic minority and are the most rural of all veterans,” Dr. Shore said. “They also proportionately have higher rates of PTSD and other deployment-related issues. The geographic isolation, access barriers, poverty levels and cultural attitudes create challenges for getting help, especially if it requires traveling outside the reservation.
The VA bridges cultural diversities by partnering with local Indian Health Services and tribal councils. The TOWs also work as liaisons to help VA staff better understand issues relative to reservation lifestyles.
“Native Americans have a complex historical relationship with the United States government that may or may not be positive, so building trust is important,” Shore explained. “Their family and community concepts differ from other non-Native rural vets so transcending cultural barriers is essential to success.”
Many patients Shore has treated are Vietnam veterans still struggling with untreated PTSD and depression. A former Vietnam veteran is maintaining his sobriety and employment after PTSD teletherapy, and ongoing participation in a telehealth support group has helped him break over three decades of alcohol abuse, job instability, broken relationships and self-imposed isolation. According to his case report, he says he never realized how his war experiences—including the deaths of all his team members—continued to negatively impact his life until he received PTSD treatment.
Indiana, too, is turning to telemedicine as the means to provide rural veterans with more timely assistance. The Indiana Veterans Behavioral Health Network (IVBHN) connects rural community mental health centers in five Indiana counties to the Roudebush Veterans Administration Medical Center telebehavioral health hub in Indianapolis. Using funding from a $536,660 three-year Health Resources and Services Administration (HRSA) planning grant, IVBHN began operation in December and should be fully on-line by June.
“Large numbers of our veterans are not getting care during those critical first months when timely interventions can best prevent unnecessary suffering and worsening of symptoms,” Project Director Bob Strange said. “Telebehavioral health prevents emotional deterioration while maintaining access to medications.”
Leif, who served as a gunner doing convoy security in Kuwait and Iraq with the Army National Guard, returned home angry and depressed. His spine had been injured in combat, but his injuries were also psychological. For two years, he says, he drank every day from morning to night to self-medicate himself.
When he experienced his first panic attack, he says, “My neck clenched. It was an overwhelming feeling, like a sniper was pointing at me.” He would drive fast on the freeway because he felt like he was still in a “Kill Zone,” and he began to have suicidal thoughts. As a result, he could not hold down a job. Leif eventually sought help from the Veterans Administration (VA), where he found camaraderie with other veterans who had experienced similar symptoms, including Vietnam Vets who had recovered from PTSD who served as advisers to the group.
Source: The VA’s Make the Connection web site, which offers veterans’ accounts of post-combat adversities and their steps to recovery.
J.T.
J.T. served in an infantry unit in Vietnam from for a year, starting in May of 1968. He was awarded the Bronze Star for Valor and the Army Commendation Medal. After his return home, his PTSD symptoms began, with “repeated nightmares of events in Vietnam, rage and anger, and anxiety.” He experienced depression and fought suicidal thoughts, and also had difficulty with authority figures. "He says he began using alcohol and drugs, as many other PTSD sufferers have, "to self-medicate in order to sleep, relax or still anger.”
By 1990, he had “hit bottom” and contacted the VA for help. A counselor from his local Vet Center in South Dakota helped get him into drug and alcohol abuse treatment at the VA. He also now participates in a closed group of vets with PTSD who meet once a week at the Vet Center. JT says that he has found that “medication, regulated by a physician, and the Vet Center group are beneficial in helping me to live a normal life.”
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