Chiseled into the granite facade of VA's Central Office are the words of Abraham Lincoln: "To care for him who shall have borne the battle and for his widow and orphan." With the growing number of women serving in the military, including many who have experienced combat exposure, we revise those words in our hearts and minds to clarify our core VA mission: "To care for those who shall have borne the battle and for their families and loved ones." What is our approach to accomplishing that mission? As VA and as a Nation, what is our approach to post-combat care?
Nearly 2.5 million U.S. troops have been deployed to the Iraq and Afghanistan theaters of conflict since 9/11. Many have had several deployments, often lasting more than a year, with downward trends in the intervals between deployments. The health concerns of those returning from deployment span a spectrum of co-occurring conditions, such as physical injury with chronic pain, diagnosable and sub-threshold mental health conditions, residuals of traumatic brain injuries, hearing loss, concerns about environmental exposures, and impairments in psychosocial functioning.
Building on lessons learned from the experiences and needs of Veterans from earlier conflicts, particularly those who served in the Vietnam War and Gulf War I, VA has transformed its approach to post-deployment care, moving to a much more systematic, structured, and integrated approach. The approach involves interdisciplinary teams conducting collaborative assessments of post-deployment physical, psychological, and psychosocial functioning through a primary care team-based, integrated model of care that ultimately has served as a model for VA's Patient Aligned Care Teams (PACT). This model of care is Veteran-centered, beginning with an expression of appreciation for the Veteran's service, an acknowledgment of the sacrifices that service has involved for the Veteran and his/her family, and attentiveness to the Veteran's story. The Post-Deployment Integrated Care Initiative (PDICI) model, launched in 2008, was shaped by clinical and epidemiological research on similar populations with complex presentations and co-occurring health concerns that involve physical, psychological, and psychosocial impairments. Since then, PDICI has undergone continuous adaptation and improvement in response to ongoing clinical, epidemiological, and implementation research. A 2010 study revealed that, within 18 months of PDICI implementation, 84 percent of VA Centers nationally had put in place integrated care platforms, teaming up medical providers, mental health providers, and social workers; the data also revealed enhancements in team function on the care teams.
Several developments in post-deployment care have emerged from the Iraq and Afghanistan conflicts, including the OEF/OIF/OND Program, the Polytrauma System of Care, the Primary Care/Mental Health Integration Program, enhanced mental health services, substance abuse and pain management services, and education/tertiary care support for Veterans and their families through the Office of Public Health and the War Related Illness and Injury Study Centers as well as enhanced overall care integration through PDICI and PACT. VA has undertaken the critical task of hiring program and case managers to assist Veterans in navigating the VHA system, aligning services, developing integrated care plans, and supporting primary care-based team care. As these programs and systems have converged and more effectively collaborated, both in care delivery and research, what has evolved is an integrated system of post-deployment care that far exceeds anything in place for earlier cohorts of returning combat Veterans. VA no longer has "a bunch of good programs and resources for returning combat Veterans." It has a comprehensive, systematic approach to post-deployment care with strong clinical, teaching, and research components.
The goals of integrated post-combat care include comprehensive evaluation of and treatment for post-deployment health concerns as well as optimal health recovery and reintegration of Veterans into civilian life. By partnering within VA and between VA and non-VA entities, we hope to mitigate as fully as possible—from both the individual clinical perspective and the population health perspective—the downstream health impacts of deployments on the lives and families of Veterans.
This approach is fully in line with the 2013 IOM report titled Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families.
The report concludes that, to ensure successful readjustment, service members and Veterans need an array of services to meet the challenges they face when returning home. Services include diagnostic, treatment, rehabilitation, education, outreach, and community support. Furthermore, the services must be effectively sequenced and integrated, guided by implementation research and validated by outcomes research.
As a corollary to the process of linking and integrating aspects of direct clinical care, the IOM report ". . . calls on the DoD and the VA to support comprehensive analysis of both departments' data to answer questions about readjustment that are not addressed by peer-reviewed literature." The IOM report reminds us of the critical importance of linking and integrating data across departments to allow researchers to analyze many of the key questions about readjustment. The transformation of VA's post-deployment care has emerged from the classical partnership of the three Ps: patients, providers, and principal investigators. This partnership builds on the strong tradition of research and evidence-driven continuous quality improvement in Veterans' health care.