Military service members and veterans who have deployed to combat zones face elevated risks of mental health problems. While most who return from deployment are able to reintegrate successfully into civilian life, a sizable percentage experience mental health problems, including posttraumatic stress disorder (PTSD), major depression, and anxiety. These conditions can also increase the risk of physical health problems and, if left untreated, can result in significant declines in quality of life, job outcomes, family relationships, and overall well-being. The families of service members and veterans, especially those who are in a caregiving role for a wounded, ill, or injured veteran, also face greater risks of mental health problems.
There are three main systems of care for these individuals and their families: The Military Health System (MHS), the Veterans Health Administration (VHA), and nonmilitary private and community health care providers. In recent years, these systems have responded to the growing recognition of the need to expand access and improve the quality of mental health care for service members, veterans, and their families through such solutions as collaborative care models and tele–mental health.
Despite these efforts, challenges persist in fashioning sustainable, collaborative systems of care that address mental health issues among service members, veterans, and their families. Privately funded centers and programs have sought to fill gaps in treatment and services and expand community capacity. Efforts to understand mental health issues among service member, veteran, and family populations; develop and disseminate evidence-based practices for treating mental health conditions; and oversee improvements in policies and programs have contributed to improvements.
Study Purpose and Approach
One such effort is an initiative by Welcome Back Veterans (WBV), launched in 2008 by Major League Baseball and the Robert R. McCormick Foundation. WBV provides funding to organizations that offer programs and services to help veterans and their families. Since its founding, WBV has awarded grants to academic medical institutions around the United States to create and implement programs focused on addressing the mental health needs of returning veterans and their families (see Table 1).
Table 1. Welcome Back Veterans Programs
|Emory's Veterans Program||Emory University, Atlanta, Ga.||Offers free clinical treatment for post-9/11 veterans and their family members in Georgia and the southeastern United States.||With WBV support, developed program to train community-based mental health providers to offer evidence-based treatments.|
|Duke University Veteran Culture and Clinical Competencies||Duke University, Durham N.C.||Training and supplemental implementation activities for community-based providers.||Developed intensive training models for organizations of providers, such as a model that trains 4–8 providers over six months.|
|Red Sox Home Base Program||Massachusetts General Hospital, Boston, Mass.||Offers treatment for PTSD and traumatic brain injury (TBI) among post-9/11 service members, veterans, and families in New England.||Created Home Base Institute, which will serve as a training hub for community providers.|
|Nathanson Family Resilience Center (NFRC)||University of California, Los Angeles, Los Angeles, Calif.||Family-centered approach to clinical services and education.||Developed Families OverComing Under Stress (FOCUS) Prevention Program that promotes resilience among military families. UCLA NFRC has leveraged technology to target military families who need care and to deliver training courses.|
|Road Home Program||Rush University, Chicago, Ill.||Provides clinical services for post-9/11 service members, veterans, and their families. Also offers training, military culture competency for health care providers and family caregivers.||Aims to use the FOCUS and TeleFOCUS models, developed at NFRC, to train community providers that serve military families.|
|Military Support Programs and Networks||University of Michigan Depression Center, Ann Arbor, Mich.||Offers mental health research and peer support programs. Also offers training to community partners.||The Buddy-to-Buddy program is a peer partnership model that connects volunteer veteran mentors with service members to help them address various issues and link with community resources.|
|Steven A. Cohen Military Family Clinic New York University Langone Medical Center||New York University, New York, N.Y.||Clinicians work directly with the Manhattan office of the U.S. Department of Veterans Affairs (VA) and other community partners to offer warm hand-offs, referrals, and clinical services in specialty areas, such as alcohol and substance abuse and grief and loss.||Dual-diagnosis program for veterans, service members, and their family members with addiction and co-occurring mental health issues.|
In 2010, the McCormick Foundation contracted RAND to serve as the performance-monitoring center for WBV. In 2014, RAND released a report on Phase I of WBV's activities and lessons learned. This study builds on the earlier one by including an update on Phase 2 of WBV activities (between 2013 and 2015), while also placing these activities within the larger context of the nation's evolving systems of care that address mental health issues for veterans and their families. During both phases, RAND's role was to collect data from grantees quarterly on their activities and progress, including information on the individuals receiving clinical services, partnership development, outreach and dissemination activities, education and training efforts, and challenges and goals. The RAND team also conducted quarterly calls with each grantee to discuss program activities and progress.
Notable Phase II Activities
In Phase II of the initiative, grantees focused their services on maximizing impact and aligning with the WBV aim of establishing sustainable programs that support the mental health needs of service members, veterans, and families through public-private partnerships. Activities were concentrated in four areas: delivering clinical services, training, raising awareness, and creating referral networks.
Delivering clinical services. Since 2010, WBV grantees provided clinical services to a total of 915 active component service members, 3,771 veterans, 901 reserve and guard members, and 5,146 family members in the form of screening, referrals, and treatment or care. Four of the seven WBV sites deliver clinical care services directly to veterans and their families through individual or group therapy. (Grantees use evidence-based or evidence-informed therapeutic interventions in clinical services for service members, veterans, and families.) Two other sites offer nonmedical evidence-based or evidence-informed support services to families.
In recognition of the myriad of issues that veterans and their families face, sites developed clinical services for a range of clinical issues that impact service members, veterans, and their families, including PTSD, depression, military sexual trauma, traumatic grief, and anxiety. Supplementing specialized options offered in the U.S. Department of Defense, VA, and community systems of care, grantees have offered clinical services and training courses specifically oriented toward such issues as military sexual trauma, TBI, female veterans, homeless veterans, and military families.
Training: Expanding the provider pool, enhancing competence. WBV grantees' training has focused on expanding the pool of providers who can deliver culturally competent mental health care to service members, veterans, and their families. As reported at the June 2014 all-grantee meeting, the WBV initiative rivals VA training offerings in terms of number of sessions offered and number of individuals trained. WBV outreach and dissemination activities have reached large numbers of individuals, informed them about mental health, and encouraged them to seek mental health care if they need it. Since WBV began, grantees have offered a total of 564 training sessions, attended by 28,736 learners. About half of these sessions train health care providers. Other sessions aim to educate service members and veterans, students, community members, families, friends, and legal professionals serving military populations. Grantees have also leveraged their own expertise in evidence-based treatments (e.g., Prolonged Exposure therapy from Emory University, Cognitive Processing Therapy from Duke, FOCUS from NFRC and Road Home) to increase the number of mental health providers who are trained to deliver these treatments.
Service delivery activities are beginning to have WBV's desired effect. For example, at the end of Phase II, the Duke University Veteran Culture and Clinical Competencies program reported that providers from the Center for Child and Family Health who had completed their cognitive processing therapy training delivered services to veterans and their family members. Future tracking of such effects as these will be valuable in assessing WBV efforts to expand the mental health provider pool.
Raising awareness and promoting help-seeking. Throughout Phase II, grantees conducted outreach and dissemination aimed at increasing awareness about mental health issues and services and encouraging those with mental health needs to seek help. To promote services, grantees participated in community events; organized activities for veterans, service members, and their families; met with key stakeholders; and sent information about programs to targeted audiences. Grantees recognized the importance of communicating with veterans and their families about mental health needs and about the availability of programs. Some WBV sites also partnered with other organizations to disseminate information and recruit individuals into trainings and clinical services. Programs varied in how much they invested in these activities; some leveraged media and local celebrities to help. Many programs also hired veterans as peer outreach specialists, who helped engage other veterans and also offered peer support during service delivery.
Creating referral networks: mental health safety nets. WBV has functioned as a safety net, helping ensure that service members, veterans, and families receive the appropriate mental health care. WBV can fill gaps in coverage by serving veterans, service members, and family members who may be ineligible or unwilling to seek care at VHA, MHS, or private/community health care systems or have not sought care because of financial constraints. WBV can also refer eligible patients to VHA, MHS, and private/community health care programs for long-term or more-intensive care, as needed. In this way, WBV's partnerships and referrals can improve individuals' access to appropriate mental health care from the most appropriate system. In addition, WBV's efforts to raise awareness about mental health and reduce stigma associated with treatment-seeking aim to encourage service members, veterans, and families to understand their mental health options and pursue treatment as needed.
The WBV initiative has enhanced system capacity by providing mental health services for service members, veterans, and their families—including specialized services for specific populations, such as female veterans, service members and veterans with TBI, military and veteran families, service members and veterans with substance abuse issues, and service members and veterans who have experienced military sexual trauma. The initiative also has enhanced capacity by offering training in treatment delivery and cultural competency to thousands of community mental health providers.
In sum, WBV has made strides in assisting service members, veterans, and families and in facilitating collaboration among systems of care in local communities. However, strategic efforts are needed to promote sustainability and address emerging challenges faced by MHS, VHA, and private systems of care.
As public and philanthropic support shifts and resources continue to decline following the drawdown of U.S. forces deployed overseas, WBV grantees and other programs must continue adapting to sustain their mental health service offerings and meet the demand for care. Negotiating third-party payment and expanding collaborative networks may help private mental health care programs, such as WBV, continue to build capacity and have a positive effect going forward.
Efforts must also continue to build on positive changes in MHS, VHA, and community care. Improved use of telemedicine, information technology, and public-private partnerships are promising approaches for bolstering mental health access and quality. While there is no simple, unitary solution for improving the mental health systems for care for service members, veterans, and their families, the combination of these policies and programs will help overcome access and quality challenges within and across the three main systems of care.