BUILDING COMMUNITIES OF CARE:
PUBLIC HEALTH PERSPECTIVES
AND CLINICAL PRACTICES IN
SUPPORT OF MILITARY CHILDREN
AND THEIR FAMILIES
Harold Kudler, MD.
Associate Director, VA Mid-Atlantic Mental Illness Research,
Education and Clinical Center and Duke University
Durham, NC
Rebecca I. Porter, PhD.
Commander, Dunham United States Army Health Clinic Carlisle
Barracks, PA
AGENDA
 Defining
Communities of Care
 History of a Public Health Perspective
 Building Communities of Care for Military
Children
 Community of Care Domains
 Programs that contribute to Communities of
Care
 Coordination and Recommendations
 Across states
 Throughout the Nation
 For clinical, educational, and governmental
impact
PEDIATRICIAN-TURNED-CHILD
PSYCHOANALYST D.W. WINNICOTT ONCE
SAID: THERE IS NO SUCH THING AS A BABY
No child exists in isolation
 Military children develop through their relations with
their military parents, other family members,
caretakers, schools, communities, and the culture and
operational tempo of the armed forces
 That’s what makes them military children

THINKING PRESENT AND FUTURE
 DoD
estimates that 57 percent of active duty troops
serving in 2011 were the children of current or
former active-duty or reserve service members
 To understand and promote the growth and health
of military children, for their sake and for the sake
of our nation, we must consider interactions that
extend across families, communities, culture and
time
 How does a nation develop communities of care that
maximize resilience and minimize the health risks
that military children and their families face?
DEFINING COMMUNITIES OF
CARE

We define Communities of Care as complex systems
that work across individual, parent/child, family,
community, military, national and even international
levels of organization to promote the health and
development of military children
A HISTORICAL PRECEDENT
Military medical history
demonstrated long ago that
merging clinical and public health
approaches can effectively help
service members cope with the
stress of deployment
 An outstanding example is the
work of Dr. Thomas Salmon who
served as chief consultant in
psychiatry for General Pershing’s
American Expeditionary Force
during World War I

A LESSON FROM WORLD WAR I
European military medical experts approached
shell shock through a clinical model
 Soldiers stayed in the trenches until they
developed all its signs and symptoms

A HEALTH SURVEILLANCE STRATEGY
ALIGNED WITH MILITARY CULTURE
Attention and prompt action were instrumental
to helping their buddies, helping their units and
accomplishing their mission
 Military culture sees the health and success of
the individual as inseparable from the health and
success of the group: fertile ground for merging
clinical and public health models of care

AS EASY AS PIE
Salmon’s doctrine of proximity, immediacy and high
expectancy of success came to be known as the PIE
model and remains a central principle of combat
medicine today
 Combat Stress Control Teams across Iraq and
Afghanistan have a 97 percent return-to-duty rate

BUILDING COMMUNITIES OF CARE FOR
MILITARY CHILDREN

To apply Salmon’s principles to military children, we
must first determine where their “front lines” are,
identify the clinical and public health supports
available to them, and apply a few basic tenets:
All warfighters and all of their family members (including
children) face difficult readjustments in the course of the
deployment cycle
 Population-based approach is less about diagnosing an
individual patient than about helping individuals, families,
military units, and entire communities retain or regain a
healthy balance despite the stress of deployment
 In the life of the family and the child, each developmental
step builds on the relative success of previous steps

DYNAMIC PRINCIPLES IN WORKING WITH
MILITARY CHILDREN AND THEIR FAMILIES
•
•
•
Military parents’ resilience and vulnerability affects the
resilience and vulnerability of their children
Clinical experience suggests that children may be the
most sensitive barometers of their family's adaptation
Each family brings its own capacities and liabilities to
the coping process, and each has successive
opportunities to adapt over the course of the
deployment cycle and in the years after
GUARD AND RESERVE CHILDREN FACE
UNIQUE CHALLENGES
Usually live far from military bases, treatment
facilities or TRICARE providers
 Often strangers to the institutions of military life
 Many of these families did not think of
themselves as “military” until plunged into the
deployment cycle of our recent wars
 Less likely to have the steady companionship of
other military children or reliable access to
military child or family programs

THE DOMAINS OF COMMUNITIES OF CARE


Communities of care improve access to information
and support through concerted action across clinical
and public health domains
Successful communities of care require innovative:
Policy
 Practice

THE SHIFT TO TRICARE




The accelerated operational tempo in Afghanistan and Iraq
drove a shift of military children out of care in military
facilities and into civilian practices under TRICARE
Unfortunately, TRICARE doesn’t mandate “basic training”
for providers so there is no guarantee that these providers
understand military culture or deployment stress or their
effects on military children
Nor is there a guarantee that enough pediatricians, child
mental health professionals or family therapists will be
available to meet the needs of military children wherever
they reside
Guard and Reserve members, whose TRICARE benefits may
be limited to the period immediately before, during, and after
deployment, also face the difficult decision of whether to
change pediatricians if their usual provider doesn’t accept
TRICARE
ARE COMMUNITY PROVIDERS PREPARED?

A recent survey of community providers (mental health and
primary care combined) found that 56 percent don’t
routinely ask patients about military service or military
family status




http://www.mirecc.va.gov/docs/visn6/Serving_Those_Who_Have_S
erved.pdf
Few had served in the military or trained in DoD or VA
health systems
Only 29 percent of community providers felt that they knew
how to refer a veteran to VA care
How can we assist community providers and advocate for
military families?
ENVISIONING COMMUNITIES
OF
CARE
DoD has tremendous capacity to support service
members and their children through clinical and
family services but there are limits …
 Community response must be flexible enough to
track military families and their children as they
change over time
 Military children don’t wear uniforms but they
should not go unrecognized and unsupported in
their communities

OBSTACLES TO BUILDING
COMMUNITIES OF CARE
Health-care providers are trained focus on
discrete diseases but communities of care require
a broader perspective
 Many issues can affect families and children,
creating a wide array of clinical and nonclinical
needs

PTSD AND OTHER DEPLOYMENT HEALTH
PROBLEMS COEXIST WITH AND ARE STRONGLY
AFFECTED BY NON-CLINICAL ISSUES
One of the most important predictors of whether combat
veterans develop PTSD is their level of perceived social
support from their families
 Difficult economic times are likely to exacerbate their
PTSD, depression, substance abuse, chronic pain or
other health problems
 PTSD or TBI may contribute to homelessness for
veterans and their families
 Even the best clinical practice guidelines for deployment
health problems need to incorporate public health
perspectives

THE BEST ARENA FOR
INTERVENTION IS OFTEN THE
COMMUNITY RATHER THAN THE
CLINIC BUT HOW DO WE ENSURE
THAT THERE IS NO WRONG DOOR
TO WHICH SERVICE MEMBERS
AND THEIR FAMILIES CAN TURN
FOR THE RIGHT HELP?
MILITARY PROGRAMS THAT SUPPORT
COMMUNITIES OF CARE
Family Readiness Groups (FRGs) connect
families with their service member’s unit and
with one another
 The FRG is the commanders’ tool
 Online virtual FRGs promote community support
and continuity for geographically dispersed units

MORE MILITARY PROGRAMS
 Military
OneSource
 RealWarriors.Net
 AfterDeployment.Org, offers links to information,
support and clinical resources
STILL MORE MILITARY PROGRAMS



The Office of Deputy Assistant Secretary of Defense of
Military Community and Family Programs coordinates
Quality of Life Programs
The Defense Centers of Excellence (DCoE) for Psychological
Health and TBI
Military Kids Connect
FAMILIES OVERCOMING UNDER
STRESS (FOCUS)
UCLA and the Harvard School of Medicine
collaboration
 A preventive intervention that teaches children and
families to cope with difficulties
 The Navy’s Bureau of Medicine and Surgery adopted
FOCUS through a contract with UCLA in 2008

FOCUS AS A BUILDING BLOCK OF
COMMUNITIES OF CARE
Detect stress early and effectively promote family and
community resilience
 FOCUS uses the same principles in civilian
communities (sometimes through online resources)
 FOCUS is scalable and portable, and can be tailored

NATIONAL GUARD PROGRAMS
 NG
Family Assistance Centers open to all
military families
 Operation: Military Kids (OMK), a collaboration
with communities to support National Guard
and Reserve children affected by deployment
MILITARY PARTNERSHIPS
 4-H
Clubs, a program of the US Department of
Agriculture, partners with Army, Air Force, and
Navy to support military children
 Boy
Scouts of America serves 19,750 military
children annually on bases around the world
THE NATIONAL RESOURCE
DIRECTORY




Joint effort of Departments of Defense, Veterans Affairs and
Labor to connects wounded warriors, service members, veterans,
and their families and caregivers with helpful programs and
services through a virtual community
NRD’s greatest weakness derives from its vast ambition
Practical solution modeled by WarWithin.org, a demonstration
project of the Citizen Soldier Support Program
WarWithin.org – effective model of how to develop and maintain
state-by-state content make the National Resource Directory
more timely, accurate and useful
CIVILIAN RESPONSES THAT
SUPPORT COMMUNITIES OF CARE



The National Military Family Association (NMFA) and the Military
Child Education Coalition (MCEC): excellent examples of civilian
organizations that effectively mobilize civilian communities
Zero to Three: develops high quality training and education to meet the
needs of military families and infants
Give an Hour: organizes health professionals and others who volunteer
free services to meet the mental health needs of service members and
their families – including Community Blueprint
THE MILITARY CHILD
EDUCATION COALITION (MCEC)
MCEC helps families, schools, and communities
support military children throughout their
academic careers
 MCEC initiates innovation to advocate for
military-connected kids – such as Living in the
New Normal Institute (LINN-I)

SESAME STREET’S
TALK LISTEN CONNECT
NEW PARTNERSHIPS TO BUILD
COMMUNITIES OF CARE

Paving the Road Home, a program of the U.S.
Substance Abuse and Mental Health Services
Administration (SAMHSA)


Policy Academies bring together state-level teams of
community mental health and substance abuse service
leaders, DoD and VA representatives, and veterans’ service
organizations
Every US state and territory has attended at least one
SAMHSA Policy Academy
WORKING STATE BY STATE
The North Carolina Focus
 Replication in Virginia and Beyond

Working at the National Level
o
o
Joining Forces
Each of the Nation’s 152 VA Medical Centers will
hold a Community Mental Health Summit before
9/15/2013
NEXT STEPS: EVIDENCE-BASED,
EFFECTIVE COMMUNITIES OF CARE
The first lesson: Identify military children
 The second lesson: No single approach to serving our
nation’s military
 Look for synergy among multiple programs rather
than choosing among approaches and services

RECOMMENDATIONS: FROM CLINICAL
PROGRAMS TO COMMUNITIES OF CARE
1.
2.
3.
4.
5.
Clinicians should ask, “Have you or someone close to
you served in the military?”
Military history and military family status should be
highlighted in each person’s medical record so that it
is noted at each encounter
Incentivize military history taking to improve health
outcomes and reduce healthcare costs
Teach all program staff about military culture and
basic deployment mental health
Register the names of clinical programs that follow
such guidelines in the National Resource Directory
RECOMMENDATIONS FOR EDUCATIONAL,
OCCUPATIONAL, CONGREGATIONAL, LOCAL
GOVERNMENTAL AND OTHER COMMUNITY
SETTINGS
1.
2.
3.
4.
5.
6.
7.
Note military connection in school records
Employers and EAPs note military-connected
employees
Clergy leaders be aware of the presence and
contributions of military families
State and local governments train on military
Campus faculty and staff build on best practices
All governments and communities commit to fully
update the National Resource Directory
Librarians in all settings promote the National
Resource Directory
IMPLEMENTING SALMON’S VISION




PIE principles provide a strong foundation to build
communities of care for military children
Focus on recognizing military children and
addressing their problems in close proximity to their
homes, schools, community organizations and doctor’s
offices
Identify their needs with immediacy by watching for
early warning signs of stress rather than waiting for
the development of clinical disorders
Proceed with high expectancy that military children
will continue to cope, grow, and succeed as valued
citizens of their communities and their nation
THERE IS SUCH A THING AS A
MILITARY CHILD
Military children and their families constitute
one of the largest American subcultures yet they
are also one of the least visible
 These children are embedded in families and
communities and in a military culture that
values humility and self-sufficiency
 They strive to put the needs of others (including
their military parents) above their own

EFFECTIVE COMMUNITIES OF CARE
Measured by their public awareness of military
children
 The distinguished physician and medical educator
Francis Peabody once said that “the secret of the care
of the patient is caring about the patient”
 The secret of creating communities of care for military
children is creating communities that care about
military children
 This will require effort and time, but we believe it is an
attainable goal.

SUMMARY
 Defining
Communities of Care
 History of a Public Health Perspective
 Building Communities of Care for Military
Children
 Community of Care Domains
 Programs that contribute to Communities of
Care
 Coordination and Recommendations
 across states
 throughout the Nation
 For clinical, educational, and governmental
impact
QUESTIONS?
Harold Kudler, MD: Harold.Kudler@va.gov
Rebecca Porter, PhD: rebecca.i.porter2.mil@mail.mil