Photo by TSgt Lynette R. Olivares
Welcome Back Veterans (WBV) is a pioneering initiative that funds programs developed by academic medical centers to expand and improve mental health care for service members, veterans, and their families. A team of RAND researchers monitored the program’s progress and accomplishments and drew lessons learned for future initiatives. The RAND team also examined the current mental health care environment in which service members, veterans, and their families seek and receive services. This environment continues to evolve as new initiatives, some like WBV, emerge to boost the private sector’s capacity to provide high-quality services to these groups. However, significant challenges persist in meeting this population’s demand for mental health care. These are challenges that newly emerging private initiatives must address to succeed and to sustain their efforts.
Deployment Increases Mental Health Risks
Service members who deploy to combat areas are at heightened risk of mental health problems. Since 2001, the United States has deployed 2.8 million individuals to support operations in Afghanistan and Iraq. While most veterans adjust successfully to postdeployment life, the mental health and behavioral challenges confronted by many have been well documented (see sidebar).
Families of service members and veterans may face mental health risks of their own, especially those who play a caregiving role. These can include declines in mental health, increased behavioral problems among children, higher divorce rates, and increased risk of suicide.
As the extent of veterans’ mental health needs has become clearer, efforts to expand access to care and improve quality have become national priorities. The government agencies charged with meeting the health care needs of veterans — the Military Health System (MHS) and the U.S. Department of Veterans Affairs (VA) — received substantial budget increases and put these to use ramping up capacity by hiring more providers, investing in research to identify other improvements, and creating clinical and research consortia to improve capabilities.
However, a continuing shortage of skilled providers and other barriers limit the reach of these systems. For example, because VA eligibility is restricted to veterans who meet certain requirements based on the nature and length of service, fewer than half of the 22 million veterans in the United States are enrolled in VA care.
The Emerging Landscape
Many service members, veterans, and their families have turned to community-based providers for help with mental health–related needs. Congress has accelerated this trend by expanding veterans’ access to care outside the VA as a way to meet demand. Community-based providers have encountered a steep learning curve developing the expertise and cultural competence to deliver evidence-based services to the veteran population.
At the same time, new programs, such as WBV, have emerged that attempt to fill gaps in the nongovernmental mental health care system (see table on next page). Some of these new programs deliver clinical services directly to service members, veterans, and their families, while others connect trained providers with those seeking care. As these programs unfold and new ones emerge, they are likely to face a series of challenges and opportunities that will determine their ability to meet their ambitious goals in future years.
Shrinking donor base. Philanthropic support for service members and veterans increased sharply when the United States entered the conflicts in Afghanistan and Iraq. These programs typically provide free services in mental health and other areas, funded by donor grants. Today, more than 40,000 nonprofit organizations focus on veterans and the military community. Yet this number has been gradually decreasing since its peak in 2011. Some programs have attempted to respond to shifting donor priorities by adapting their service models to the current grant environment. A more sustainable approach in a resource-constrained future will involve partnerships with other private entities and with the government.
Third-party payments. Negotiating payments from third-party payers, such as the VA or TRICARE, is another way for private mental health programs to improve the sustainability of their funding streams. Although there are logistical and administrative costs associated with setting up participation in payer networks, the investment in doing so will offer dual benefits in improving program sustainability and increasing access to mental health services among veterans and their families, particularly at a time when both the U.S. Department of Defense (DoD) and the VA are increasing their reliance on community providers.
Coordination and integration of services. MHS, the VA, and private providers operate largely in separate systems, with occasional contact points where coordination occurs, but no systemic integration. The burden of navigating these systems falls on patients and their families. As a result, these systems may refine best practices in specific areas, such as telemental health or collaborative care, but are missing opportunities to learn from each other or facilitate improvements across systems.
Examples of Community-Based Programs for Veteran Mental Health
|Welcome Back Veterans Initiative||Expand access to high-quality mental health care for service members, veterans, and their families||Grants to academic medical centers to offer services to veterans, and their families, as well as training programs for health care providers|
|Warrior Care Network||Improve access to clinical care for service members and veterans with PTSD, TBI, and related conditions||Partnership between Wounded Warriors Project and four academic medical centers: Emory, Massachusetts General Hospital, Rush, and UCLA|
|Cohen Veterans Network||Offer free outpatient mental health care to 50,000 veterans by 2021||A national network of 25 clinics offering free mental health services to veterans and their families|
|Headstrong Project||Offer evidence-based treatment to post-9/11 combat veterans||Developed at Weill Cornell Medical College in New York City; has expanded to several other U.S. cities|
|Specialized Provider Registries||Enhance provider sensitivity, competence, and skill sets, and connect these providers with service members, veterans, and their families||There are several registries focused on specific aims and serving different geographic areas, including Give An Hour and Star Behavioral Health Providers|
Many service members, veterans, and their families have turned to community-based providers for help with mental health–related needs.
Information-sharing. Sharing information across systems can help drive collaboration and lead to partnerships, but there are technical and statutory barriers. For example, DoD, the VA, and the Warriors Care Network use separate recordkeeping systems whose compatibility is not known.
Despite these challenges, opportunities exist for improving coordination between systems of care and private programs. One promising strategy involves extending and enlarging collaborative networks. To enhance impact and strengthen sustainability, WBV grantees have developed local partnerships to overcome barriers to care. They have also used their relationships with each other to collaboratively launch other efforts intended to fill gaps.
Two other examples of collaborative networks that have expanded and improved partnerships to better serve the veteran and military communities are AmericaServes and America’s Warrior Partnership. Each of these networks focuses on connecting service providers across many domains with each other and with veterans in their community. Each network relies on an information system and technology infrastructure to facilitate connections and works with public and private organizations.
Along with WBV, AmericaServes, and America’s Warrior Partnership, there is a vast range of national and local collaborative networks working to provide mental health care for service members, veterans, and military families. This also includes newer initiatives, such as the Warrior Wellness Alliance recently launched by the George W. Bush Institute. These networks overlap and connect in various ways. Many work directly with the VA, MHS, and common national and local partners. Collaborative networks can offer value to the greater mental health field by sharing lessons learned, best practices, and service models for replication.
To benefit from this model of collaborative networks, participants need to:
- form new connections with other networks.
- invest in building better connectivity across networks.
- work to energize public engagement and support through advocacy as part of a strategy to sustain program funding.
The mental health care landscape for service members, veterans, and their families is complex, with persistent challenges. To address these, private-sector care is assuming a more prominent role. In this context, WBV and other emerging private initiatives are positioned to fill gaps in the existing systems and to point the way toward a more coordinated and integrated vision of national efforts to meet this population’s mental health needs.
- New private-sector programs, such as those created by Welcome Back Veterans, are emerging to fill gaps in the mental health care system for veterans.
- These programs face sustainability challenges from relying on donors. Negotiating payments from third parties, such as insurers, could help address this challenge.
- Programs also face issues coordinating and integrating their services with the broader veterans’ mental health network. A collaborative network approach that strengthens ties across both government and private- sector mental health systems could address these issues