Community Health Care Providers
and Military Cultural Competence:
Findings from a Web-Based
Survey of Provider Needs
Harold Kudler, M.D.
Associate Director, VA Mid Atlantic Health Care Network Mental Illness
Research Education and Clinical Center (VISN 6 MIRECC)
Clinical Lead, VISN 6 Rural Health
Associate Professor, Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center
[email protected]
A Little History
• Joint DoD/VA Planning for the First Gulf War,
Ft. Benjamin Harrison, December 1990
• Military Medical System to “saturate” after two
weeks of combat
• VA system to provide next fallback
• National Disaster Management System (NDMS)
would then progressively enlist the efforts of every
medical system in the nation including university
and community hospitals and practices
• As a Nation, we dodged this bullet but where are
we now?
What the Data Tells Us About
Our National Capacity to
Manage Deployment-Related
Mental Health Issues
• Of 22.2 million living Veterans, 8.3 million
(roughly 1 in 3) are enrolled in VA Healthcare
• Nearly three-quarters served during a war or
an official period of conflict
• VA currently provides health care to 6.2
million veterans (roughly 1 in 4 Veterans)
OEF/OIF/OND Veterans In VA
• Approximately 54 percent (771,874) of all eligible
OEF/OIF/OND Veterans (includes Reserve
Component Members) have used VA health care
since October 1, 2001
• A total of 476,811 of these accessed VA care
during calendar year 2011
• Those who use VA care seem to value it
• 52% (434,552) of all OEF/OIF/OND Veterans who
have presented to VA have received at least one
provisional Mental Health diagnosis
Beyond the DoD/VA Continuum
• Ideally all deployment-related Mental
Health problems would be picked up
somewhere within the DoD/VA
continuum of care but:
• Despite their historic level of
engagement in VA, if 54% of OEF/OIF
Veterans eligible for VA care have come
to VA where are the other 46%?
Comparison to the National Vietnam
Veterans Readjustment Study
• Perhaps we should only be concerned
about those who choose to seek care but:
• Only 20% of the Vietnam Veterans with PTSD
at the time of the study had EVER gone to VA
for Mental Health Care yet:
• 62% of all Vietnam Veterans with PTSD had
sought MH care at some point
Kulka et al. 1990, Volume II, Table IX-2
Service Members, Veterans and their Families are
Distributed Across the Entire Nation and Many
Seek Care Within Their Own Communities
• An estimated 25-50% of OEF/OIF/OND Veterans
seen in DoD/VA also receive part of their care in
the community
• Family members also deal with deploymentrelated stress and virtually all of them seek
care in the community
• Are Community Providers and Programs
prepared to identify, treat or triage
deployment-related mental health problems?
Serving Those Who Have Served:
Educational Needs of Health Care
Providers Working with Military
Members, Veterans, and their Families
• Web-based survey of 319 rural and urban community
mental health and primary care providers
• Available at VA Internet Link:
• Funded by VA’s Office of Rural Health
Kilpatrick, D.G., Best, C.L., Smith, D.W., Kudler, H., & CornelisonGrant, V. Charleston, SC: Medical University of South Carolina
Department of Psychiatry, National Crime Victims Research &
Treatment Center, 2011
• 97.6% participation rate among 327 providers
who opened link
• Two-thirds were mental health professionals
• Psychologists were most prevalent group followed by
psychiatrists, social workers/ other mental health
• Remainder self-identified as primary care providers or
other professionals
• Most prevalent were family medicine providers
followed by pediatricians and internists
• One-third (34%) self-described as Rural
• 6% were not sure if Rural or Urban
The Rural Dimension
• Rural Veterans
• 41% of all VA enrollees
• 39% of enrolled OEF/OIF/OND Veterans
• Rural Service Members (including Guard
and Reserve Members), Veterans and their
families are less likely to have access to a
local mental health professional
Experience with Military/Veterans:
Military Cultural Competence
• Only one out of six (16%) providers had ever served
in the Armed Forces including the Reserves or
National Guard
• Although VA is a national leader in provider training,
only one in three (31%) had any VA training
• Only one out of eight (12%) have ever been
employed as a health professional in VA
Key Findings of Serving
Those Who Have Served
• 56% of community providers don’t routinely
ask their patients about being a current or
former member of the Armed Forces or a family
• Only 29% of providers agreed with the
statement: “I am knowledgeable about how to
refer a Veteran for medical or mental health
care services at the VA”
An Important Educational
• The largest group of providers (48%) reported
“no hesitancy” in referring patients to VA
health care but:
• 34% percent had neutral responses about
referring to VA
• Providers with neutral opinions can be
converted to advocates if provided with more
• More than half of all respondents (58%) want to
know more about eligibility requirements for VA
Disparities in Knowledge and Confidence
Among Community Providers: Rural Matters!
• Rural Providers were significantly more likely to
be primary care professionals
• No significant difference in military service but
Rural Providers were significantly less likely to
have been employed by VA
• A significantly smaller percentage of Rural
Providers said they routinely screened their
patients for Military, Veteran or family status
• 37% of Rural vs. 47% of Non-Rural
Disparities in Knowledge and Confidence Among
Community Providers: Rural Matters!
• Rural Providers were significantly more likely than
Non-Rural providers to disagree that they were
knowledgeable about best practices in treating
depression, substance abuse/dependence and suicide
• 26% of Rural Providers disagreed with the
statement that they felt knowledgeable about
treating depression vs. 16% of Non-Rural Providers
• 26% of Rural Providers disagreed with the
statement that they felt knowledgeable about
treating substance abuse/dependence vs. 15% of
Non-Rural Providers
• 37% of Rural Providers disagreed with the
statement that they felt knowledgeable about
managing suicide vs. 24% of Non-Rural Providers
Disparities in Knowledge and Confidence
Among Community Providers: Rural Matters!
• No significant differences in professed knowledge on
treating PTSD, TBI or Family Stress & Relationship
Problems BUT:
• Rural Providers were significantly less confident about treating
PTSD than their Non-Rural counterparts
• 46% of Rural disagree about confidence vs. 35% Non-Rural
• Rural Providers were also significantly less confident about
treating depression
• 26% of Rural disagree about confidence vs. 15% Non-Rural
• The same pattern held for confidence about managing suicide
• 37% of Rural disagree about confidence vs. 24% Non-Rural
If You Don’t Take the Temperature,
You Can’t Find the Fever
• Community Providers should ask every
patient: Have you or someone close to
you ever served in the Armed Forces?
• Potentially the key driver of change in
Next Steps
• Implementation Science Approach
• Can we change provider practice by
• Increasing rate of screening for Military History?
• Increasing rate of referral to VA?
• Can we improve deployment health outcomes?
• Public Health Orientation
• Can we engage the entire DoD/VA/State and
Community Continuum of Care in
deployment mental health?
Challenges in Future Studies
• Access a representative sample of
sufficient size
• Randomization that allows for analysis of:
• Rural vs. Urban
• Mental Health vs. Primary Care
• Health disparities by race, ethnicity and
Challenges in Future Studies
• Design an Appropriate Intervention
• Veteran Driven
• Place sign in waiting room
• If you or someone close to you has served in the military, please
tell us. We want to know.
• Academic Detailing
• Office visits by colleagues (through professional
organizations) vs. Veterans (individually as peer advocates
or through Veterans Service Organizations), Family
members or other stakeholders
• Evidence-Based Teaching
• Conduct survey of Military/Veteran and Family treatment
preferences and send findings to community providers
Draft Referral Guide for Community Providers:
Framing Desired Behaviors in 6 Point and Click Terms
1. For Veterans, friends or family members looking for
information, resources, and solutions to issues affecting
their health, well-being, and everyday lives—all in the
words of Veterans:
• Make the Connection.Net
2. For OEF/OIF/OND Veterans ready to enroll in VA Care:
3. For Veterans of all other Service Eras ready to enroll in VA
• Phone, mail, web-based or in-person assistance in enrollment
Draft Referral Guide for Community Providers:
Framing Desired Behaviors in 6 Point and Click Terms
4. If You are in an Emergency or Homeless:
• Veterans Crisis Line
• 1-800-273-8255
5. If You are a Family Member concerned about a Veteran:
• Coaching Into Care:
• 1-888-823-7458 or
6. If you are less than honorably discharged, unsure about
your eligibility or would like to learn more about VA
• Vet Center:
• 1- 877-WAR-VETS(927-8387)
Measureable Outcomes
• Increased screening for Military Service and Family status
• Increased rate of referral to VA services
• Increased Training on Military Cultural Competence
• DoD/VA Military Cultural Competence Course
• Increased engagement in VA clinical consultation
• Make The Connection
• VLER: Virtual Lifetime Electronic Record
• Shares select parts of a Veterans’ medical record electronically
with other approved health care facilities that are members of
the Nationwide Health Information Network
• MyHealtheVet and Secure Messaging
• Dual Care
• Increased satisfaction in collaboration with VA
• VA is there to complement the provider’s care, not compete with it
Modest Proposal for A Pilot Project in Partnership
With MCEC in Support of Service Members, Veterans
and their Families
• Survey of current practices including screening for
military history and referrals to VA
• Training of Membership
• Distribution of “The Sign”
• Academic Detailing by Health Professionals and/or
Guard Members
• Clocking Referrals
• Creating a Tear Sheet Referral Form
• Tracking Patient Follow Up With VA AND Local M.D.s
• Tracking Patient Health Outcomes
New Principles
A modern Military Saying:
The Military goes to war; the nation goes to the mall
• As a nation, we need to promote a public health
approach to bringing war fighters home that looks
beyond the DoD/VA continuum of care to engage the
entire community and all of its health care assets
• This follows from acknowledgment that, as citizens:
• We are all part of these wars
• We are all responsible for the care of Service
Members, Veterans and their families
• We each have a role to play in promoting reintegration
and resilience before, during and after deployment
The Vision
There will be No Wrong Door to
which ANY Service Member,
Veteran or family member can
come for the right help
With your help, this is
an achievable goal!
[email protected]

Community Health Care Providers and Military Cultural Competence