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Making a difference in the health care of veterans: 9 things you should know

      I began my clinical career in nursing as a staff nurse on a psychiatric ward at the Washington, DC Veterans Administration Medical Center (VA). The year was 1971 and many of those for whom we cared were soldiers recently returned from Viet Nam. I recall that the VA referred to the DC hospital as the “flagship” of the VA system, and according to their website, the distinction holds true today. The site reports, “We strive to only hire the best!” As an alumna, I take some pride in this message, even today. Although I found the position challenging for many reasons, I have always held a special spot in my heart for the Veterans Administration Health Administration division and its parent organization, the United States Department of Veterans Affairs. No matter what your particular politics or attitude toward the Department of Defense, the soldiers who serve on behalf of our country—on behalf of all of us—deserve our sincere respect and appreciation for their service and sacrifice, as well as our support after their service.
      I do not pretend to be an expert on veterans’ health care, but over the years, I have learned a few things that I would like to share. This information stays with me and has helped me to act on behalf of others; I offer the information to you to consider how you might act to improve the health of a veteran. If you do not see what you need to know, please ask. Your action could make an important difference.
      • 1.
        The Veterans Health Initiative (VHI) is a comprehensive program to recognize the connection between certain health effects and military service, to allow military medical history to be better documented, and to prepare health care providers to better serve their veteran patients. The VA developed the VHI to enhance VA providers’ knowledge about diagnosis and treatment of military service–related health conditions and illnesses through a set of online courses that are available at http://www.publichealth.va.gov/vethealthinitiative/index.asp.

        United States Department of Veterans Affairs, Office of Public Health and Environmental Hazards. The Veterans Health Initiative. Available at: http://www.publichealth.va.gov/vethealthinitiative/index.asp. Accessed September 6, 2010.

        The courses are accredited and satisfy medical licensure requirements and may be taken by VA employees through the VA Learning Management System. The VHI guides are useful for non-VA health care providers caring for veteran patients and for the public, who may be interested to learn more about symptoms and treatment. Topics include: Agent Orange, traumatic brain injury, cold exposures, visual impairment radiation, spinal cord injury, and war wounded—Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), among others.
      • 2.
        Enrolled veterans qualify for a comprehensive medical benefits package that provides a full range of preventive outpatient and inpatient services within the VA health care system and is portable to any VA facility across the country. Family members may qualify as well, depending on circumstances, including income. Veterans can apply for benefits online at http://www4.va.gov/healtheligibility or by phone (1-877-222-VETS).

        United States Department of Veterans Affairs. VA Health Care Overview Home and Online 10-10 EZ Application. Available at: http://www4.va.gov/healtheligibility. Accessed September 6, 2010.

        Despite this, and for a variety of reasons, many veterans do not seek care at VA facilities. For those reasons, it is important that health care providers understand the special risks that may affect the health status of veterans.
      • 3.
        Only 15% of the veteran population seeks care from the VA, making it all the more important that health professionals understand the risks associated with military service. No matter what the patient’s age or gender, every adult’s health history should include the question: Have you ever served in the military? If the answer is affirmative, a series of follow-up questions should be asked: (1) Tell me about your military experience; (2) Where and when did you serve?; (3) What did you do while in the service?; and (4) How has military service affected you? The answers to these questions give rise to particular concerns, depending on the period of service and the activities in which the veteran engaged. Those serving in WWII and the Korean Conflict may have been exposed to cold injuries, nuclear weapons, or chemical warfare. Nuclear exposures may have resulted from nuclear testing during the Cold War. During the Viet Nam War, Agent Orange exposures occurred and many veterans contracted hepatitis C. During the Gulf Wars, exposures to smoke, chemical, and biological agents were experienced. During OIF and OEF, the incidence of traumatic brain injuries, vision loss, amputations, spinal cord injury, and significant mental health issues have been associated with active military service. When the discovery of risk and exposure has been identified, the health care provider needs to understand the possible long-term effects as well as the resources available to help manage risk and the morbidities that may already be evident.
      • 4.
        Veterans returning from Active Duty combat in Operation Enduring Freedom and Iraqi Freedom are at high risk for posttraumatic stress disorder (PTSD). Although the difficulties of these veterans and their families in living with PTSD have been described, the approaches to assisting them are less frequently discussed. Evidence suggests that intervention to bolster psychological resilience and postdeployment social support may decrease the severity of traumatic stress and the incidence of depressive symptoms.
        • Pietrzak L.
        • Johnson D.
        • Goldstein M.
        • Malley J.
        • Southwick S.
        Psychological resilience and post deployment social support protects against traumatic stress and depressive symptoms in soldiers returning from Operation Enduring Freedom and Iraqi Freedom.
      • 5.
        Stigma remains one of the greatest barriers to seeking needed mental health services for veterans suffering from PTSD, and the reluctance appears to be greatest for those with the greatest need.
        • Hoge C.
        • Castro C.
        • Messer S.
        • McGurk D.
        • Cotting D.
        • Koffman R.
        Combat duty in Iraq and Afghanistan: Mental health problems and barriers to care.
        Preparing for combat is difficult. Today, the environmental conditions of extreme heat and high levels of noise combine with close quarters, limited privacy, and little sleep. Almost 90% of combatants are attacked or ambushed while in combat and almost 65% witness death or the serious injury of comrades. Nearly 50% are responsible for the death of an enemy combatant. Younger veterans are at higher risk for severe PTSD. The Department of Veterans Affairs operates a National Center for PTSD (http://www.ptsd.va.gov/).
      • 6.
        Benefit coverage has been expanded for exposure to Agent Orange. Agent Orange is the name given to a specific blend of herbicides used in Viet Nam from 1961 to 1971 during the Viet Nam conflict. The US military sprayed millions of gallons of Agent Orange and other herbicides to remove leaves from trees that provided cover for enemy forces. Many US veterans and many Vietnamese were exposed to these herbicides. On August 31, 2010, the VA published final regulations establishing all chronic B-cell leukemias, Parkinson’s disease, and ischemic heart disease in veterans as related to exposure to Agent Orange and other herbicides. After a 60-day Congressional review period, eligible veterans may receive health care and disability compensation for these diseases. An Agent Orange newsletter, the Agent Orange Review, is now available to the public.
      • 7.
        US veterans are disproportionally represented among the homeless. The National Coalition for Homeless Veterans (NCHV) estimates that 33% of all homeless are veterans. They are predominately men (95%) who are single and from urban areas, and many suffer from mental illness as well. Among homeless veterans, about 50% were active during the Viet Nam War. Roughly two-thirds served for more than three years, and one-third served in a war zone. Although the VA does provide some shelter for homeless veterans, the needs exceed the resources. In 2009, roughly 92,000 homeless veterans were served by the VA; the unmet need was estimated at another 100,000 veterans. According to the NCHV, these veterans do need housing (especially transitional housing) and basic and mental health care, but their greatest need is for sustained employment. Poverty is an enemy that keeps another estimated 1.5 million veterans at risk of homelessness.

        The National Coalition for Homeless Veterans. Home page. Available at: http://jwww.nchv.org. Accessed September 6, 2010.

      • 8.
        Each state has a Department of Veterans Affairs that can be accessed via the Internet (http://www.va.giv/statedva.htm).

        United States Department of Veterans Affairs. State/Territory Veterans Affairs Offices. Available at: http://www.va.gov/statedva.htm. Accessed September 6, 2010.

        Supplemental to the federal department of Veterans Affairs, each state provides services to its veterans and, although the benefits packages vary from state to state, they generally include some residential and health services, eligibility counseling, education benefits, and burial benefits. In selected states, campaigns are organized to connect veterans to available services; in others, surveys are conducted to determine the needs of each state’s veteran population.
      • 9.
        Each state has a Commissioner for Veterans Affairs and those are named on the website of the state Department of Veterans Affairs. I am pleased to acknowledge that the Commissioner of Veterans Affairs in the state of Connecticut is one of the few women who serve in this capacity and the only nurse. Linda Spoonster Schwartz, MSN, RN, DrPH, FAAN, retired from the US Air Force after 16 years of service, both in active duty and as a reservist, during the Viet Nam Era. She retired in the rank of Colonel. After years of veteran advocacy, she was appointed Commissioner by Connecticut’s Governor, M. Jodi Rell, in 2003. Since accepting that appointment, Commissioner Schwartz has served as an example of the mission of the American Academy of Nursing. She has used evidence to guide the development of policy. Commissioner Schwartz has initiated assessments to determine the needs of returning veterans. She has worked closely with Central Connecticut State University’s Center for Public Policy and Social Research and the Yale School of Medicine to learn more about veterans’ needs and the determinants that promote their successful transition back into their communities after discharge. However, Commission Schwartz takes her work one step further. She takes action. She testifies at the state and federal levels. She writes grants and brings new dollars to the state to transform old, outdated buildings into new health care facilities and domiciles. She forges partnerships between state agencies that can help create new opportunities for the state’s veterans. I do not have too many heroes, but Commissioner Linda Spoonster Schwartz has always been on my short list. Linda, thanks for your dedicated service and for your good example.

      References

      1. United States Department of Veterans Affairs, Office of Public Health and Environmental Hazards. The Veterans Health Initiative. Available at: http://www.publichealth.va.gov/vethealthinitiative/index.asp. Accessed September 6, 2010.

      2. United States Department of Veterans Affairs. VA Health Care Overview Home and Online 10-10 EZ Application. Available at: http://www4.va.gov/healtheligibility. Accessed September 6, 2010.

        • Pietrzak L.
        • Johnson D.
        • Goldstein M.
        • Malley J.
        • Southwick S.
        Psychological resilience and post deployment social support protects against traumatic stress and depressive symptoms in soldiers returning from Operation Enduring Freedom and Iraqi Freedom.
        Depress Anxiety. 2009; 26: 745-751
        • Hoge C.
        • Castro C.
        • Messer S.
        • McGurk D.
        • Cotting D.
        • Koffman R.
        Combat duty in Iraq and Afghanistan: Mental health problems and barriers to care.
        N Engl J Med. 2004; 351: 13-22
      3. The National Coalition for Homeless Veterans. Home page. Available at: http://jwww.nchv.org. Accessed September 6, 2010.

      4. United States Department of Veterans Affairs. State/Territory Veterans Affairs Offices. Available at: http://www.va.gov/statedva.htm. Accessed September 6, 2010.

      Biography

      Catherine L. Gilliss, DNSc, RN, FAAN, is the Dean at the Duke University School of Nursing, where she is the Helene Fuld Health Trust Professor of Nursing and the Vice Chancellor for Nursing Affairs for Duke University, Durham, NC.