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 statesThroughout the NationFor 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_Se

rved.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 Levelo Joining Forceso 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. Clinicians should ask, “Have you or someone close to you served in the military?”

2. Military history and military family status should be highlighted in each person’s medical record so that it is noted at each encounter

3. Incentivize military history taking to improve health outcomes and reduce healthcare costs

4. Teach all program staff about military culture and basic deployment mental health

5. 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 SETTINGS1. Note military connection in school records2. Employers and EAPs note military-connected

employees3. Clergy leaders be aware of the presence and

contributions of military families4. State and local governments train on military5. Campus faculty and staff build on best

practices6. All governments and communities commit to

fully update the National Resource Directory 7. 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 statesthroughout the NationFor clinical, educational, and governmental

impact

QUESTIONS?Harold Kudler, MD: Harold.Kudler@va.govRebecca Porter, PhD: rebecca.i.porter2.mil@mail.mil