Welcome to segment two on Lessons on Veteran Centered Care. We're going to focus on the social issues as they contributed to the social determinants of health. So, if you remember this from unit one, that brings overall when you look at levels of poverty actually do quite well compared to the general US population. Veterans in their ability to engage and meaningful work being members of a team actually do not find themselves in poverty at the same level as the general US populations. When we think about the veterans that are among us, if you pay attention to the black and the red bars those are current US veterans. And the percent of veterans within those levels of poverty, compared to the general US population. As we go forth in this segment, we are going to focus on veterans that have less access and are more impoverished. But I do want you to realized that that is not a generalization across all veterans. One specific population of veterans that is in the news lately, and who we spent lots of resources and are readily engaged in the homelessness among the veteran population. It's estimated that there's approximately 55 to 60,000 homeless veterans in the United States. That would account for 12% of all homeless adults. And we know that veterans are three times more likely to become homeless than the general population if they live in poverty and are from a minority group. In order to combat that, there's some work that's been done within the VA system to really bring healthcare and the concept of shelter to veterans at the point of contact, really to address this issue of the social determinants of health regarding shelter. [MUSIC] >> Providing health care services to homeless veterans is a critical priority within VA. VA health services researcher Dr. Tom O'Toole, Chief of Primary Care at the Providence Medical Center is studying ways to improve primary care services for homeless veterans. >> When you're homeless, three things happen. One is often times your homelessness is precipitated by medical illnesses, addictions, mental illnesses that make it much more difficult to get by in society. At the same time being homeless can make you more susceptible to other illnesses, frostbite, tuberculosis, other conditions. And lastly, it makes it very difficult to manage chronic illnesses like diabetes, high blood pressure, hypertension. What we have seen in our epidemiologic studies is that homeless veterans tend to be older than other homeless persons, than the general population of homeless persons. It's not entirely clear why, but they tend to be older, and often times they're homeless longer. We've made great strides and improvements over the past couple of years in trying to reduce those numbers. But they're still there, and they're still much larger than any of us would like to see. One of the problems that we've seen, is that when a homeless person comes to a primary care clinic, what do you do? Oftentimes, you're challenged by I would like to treat his diabetes or her hypertension. But at the same time, what's going to be important to them is figuring out where they're going to stay that night. Or where they're going to get their next meal. And so the challenge has always been how do we really match those competing interests and competing priorities in such a way that we can keep them in the system. And we can use the primary care encounter to get them plugged in with the services that ultimately they're going to need in order to be able to exit homelessness. What we have found in our earlier research and what we are trying to show in this work, is that by bringing a homeless person into the healthcare system and specifically the primary care system earlier. We stand a better chance of getting them into addiction services faster, keeping them in mental health services, and keeping them compliant with the medications they take, helping them with their chronic disease management. As well as facilitating a lot of the referrals to VA programs that are really essential for them to exit homelessness. We identify the homeless in several different ways. One is by community outreach and really engaging with community partners who are seeing homeless veterans in soup kitchens and an area shelters that are not part of the VA. Secondly, we really rely on the network of homeless persons, and they bring in their buddies. That no veteran gets left behind is something that they truly live by. And lastly, we've really tried to mobilize the health systems that we're working in. So that the emergency department personnel know to look at a person and see if they have a place to stay at night. And if they don't to really try to mobilize care around that person. It has been a tremendous opportunity. It's brought incredible fire power to this cause. Brought together some very bright people, and resources, to the extent now that we are really leading the country in ending homelessness and specifically for this population. It's a very exciting time to be at the VA. [MUSIC] >> So you've heard from Dr. O'Toole there is a national interest to try to end homelessness by this year, 2015, in terms of Health Care for Homeless Veterans program. There's been several states and cities that have actually met this goal and it's interesting impact that we've decided that we're going to shelter veterans at the point that we have contact with them, and then we'll help them with all of their other issues in order to support their ability to maintain housing. There's several risk factors as you heard in the video regarding homelessness in veterans. So those who are homeless and more likely to have a psychiatric diagnosis, have a substance to use disorder, have known trauma due to military service, are unmarried, unemployed, have been deployed in the past and have very low level of social support. When we think about other populations that we focus on in terms of health care disparities, one of interest and of note is that the difference between the health outcomes between white and African-American veterans is significant. We know from the data that African-American veterans achieve worse clinical outcome measures across the board when compared to white. And African-American veterans in general tend to be less satisfied with their care, and less likely to receive invasive procedures for the management of things like coronary artery disease. However, there's been a strong focus within the VA to really try to understand why those disparities are there and what you can do to help mediate and impact those disparities. Well here from international and national experts, Dr. Judith Long, who's also from the Philadelphia VA and the University of Pennsylvania. And finally, Dr. Washington who will give a perspective about women veterans and who's from the Los Angeles VA and UCLA. >> My name is Judith Long. I'm from the Philadelphia VA Medical Center, as well as the University of Pennsylvania. And I'm an Associate Professor of Medicine here. And my research is focused on in particular disparities and diabetes outcomes for veterans, and what we've noticed is quite consistently across the board that veterans have more difficulty controlling their diabetes. And what we see is that African-Americans are, at my VA we serve almost completely African-Americans or whites, so we don't have a lot of Latino or other racial populations. But the African-American veterans have worse control, and we have done some qualitative work into sort of looking at, trying to understand this. And what we find is that for African- Americans who have persistently poorly controlled diabetes, they often have different responses to stress. In that stressful situations they are often responding in more unhealthy ways. We've done qualitative work where an example quote was a veteran that said well, I got into a fight with my wife and all I wanted to do was go sit in my comfy chair, turn on the TV, and eat potato chips, which is not necessarily the most healthy response. There's also been a lot of people voice a lot of issues around temptation and dealing with temptation, more so then. So the grandkids come over, my wife makes a cake, what am I going to do? Of course, I'm going to eat that cake. That type of thing. And then one of the other things that we noted is that diabetic veterans who have poor control, they didn't dislike their doctors. They didn't distrust their doctors. They just didn't think about their doctors as being an important part of their diabetes control. And so we've done work around using peer mentors. And what we do with the peer mentors is that we find mentors that are, who were once out of control and are now in good control. And we also found that from our work that that was important because if you've always been in good control you don't understand what the person who's out of control is going through. And so with the peer mentors they were once out of control and now are in good control and we give them some training, and then they deliver sort of once a week. They check in with their mentee and work with them on their diabetes. And we really try to help the mentor work with the out of control veteran to identify what they see as their barriers, and to identify realistic steps and towards achieving better control either through exercise or diet. And we've done a study on this and we showed that it was all African-American, but we showed that veterans who received a peramint or dropped their hemoglobin a wax c which is a mark for control by 1%. Outside of the doctors appointment and they need help outside of the medical encounter. And we have seen, this is pretty true across the board, things that happen in the medical encounter over time there have been less disparities. Things like for the exams or checking the hemoglobin A1C. It's more those things that require where people have social determinants really affecting why they might be out of control, because they don't have financial resources, because their life might be more disorganized as other things. And so we're trying to do a variety of different interventions, where we're trying to help support people change their behaviors outside of the clinical encounter. I've always been very committed to working with under served populations and for the most part, veterans they're not all under served. But a lot of the veterans who are using the VA, low income, minority, under served, they're often using the VA because they have no other options. And that's always been a population I've been committed to, but since being in the VA, I actually love working with the veterans. I think they're a great group to work with, and one of the things we found in the peer mental work is that they like to help each other. That's one of the things, there's a real sort of collective advocacy around being a veteran and that veteran experience. So, I love working in the VA and I think it's a great environment. >> Before we hear from Dr. Washington if you remember from unit one, approximately 9% of all veterans are females. It's the fastest growing population within Veterans Health Administration enrollees. They consistently report poorer health outcomes than civilian females and there is a larger prevalence of mental health disorders such as panic attacks, anxiety, and depression when you compare female veterans to male veterans. >> Hello, I'm Dr. Donna Washington from the VA Greater Los Angeles System. I'm a primary care provider in the Women's Health Clinic. I lead the women's health focused research area and our health services research center of innovation. I am director of the Office of Health Equity Quality Enhancement Research Initiative Partner Evaluation Center. And I am a professor of medicine at UCLA. Much of my patient care and research activities center around women veterans. Women veterans have many of the same health concerns as non-veteran women but they're unique in several important ways. During military service, many women serve in war zones and are exposed to combat. In fact, after 9/11, over two-thirds of women serving in Iraq and Afghanistan served in a combat or war zone. Women of all military eras have also been subjected to physical assault, repeated sexual harassment and sexual assault during the military service. Many of these exposures and experiences during military service may have long lasting physical health and/or mental health including chronic pain syndromes and post traumatic stress disorder. Though these health effects in military service are often immediately evident, sometimes they may take years or even decades to surface. I've heard veteran-centric care described as a personalized, proactive, patient-centered approach to healthcare that it is driven by the individual needs and properties of veterans even the complex physical health, mental health, and psychosocial concerns a women veterans. I think that adopting a veteran centered approach requires understanding what it is that each veteran would like from their healthcare experiences. Now, I know it might sound cliche to say that each individual's unique, but once you start asking patients about their lives, their values, and their views of their health and healthcare, you'll leave behind any notion that anything other than a patient centered approach is optimal. A veteran centered approach to caring for women veterans can begin with simply asking how we can help them live their life more fully. When I was in medical school I wanted to be a primary care provider and to conduct health services research so that I could both positively impact the lives of individuals and improve the healthcare system. During my training what I discovered is that Department of Veterans Affairs settings are the ideal place to accomplish both. They have diverse patient populations, a fantastic electronic medical records system, and it is a setting that values patient centered care, quality of care and research. I hope that you to will find that VA settings are an ideal place to deliver patient incentive care or to receive it. So when we think about the social determinants of health which of the following are potential sources of disparities among rural veterans, lack of access, lack of social support. They don't need as much medical care, or lack of education are potential options, as rural veterans are also a specific population for us to think about. There is a lot of controversy between and regarding access to health care resources between urban and rural veteran populations. This has been the media quite a bit. It's one of the reasons why congress has acted in terms of the Veteran Choice Awards, in order to improve access. But when we think about specialty care for veterans in particular, but for the U.S. general population, specialty care services often reside in large urban facilities. And those who live and need to travel distance often that restricts their access, and there's a under utilization of those services due to distance. One way that the VA healthcare system and other large networks here in the United States have really thought to address the rural versus urban dilemma is to really think about Telehealth and using technology as a way to have large impacts across healthcare both for primary care and also specialty care. There are several programs within the VA in terms of simple things with Telederm, Telerethnic Hair where pictures are taken, sent to the specialist, the specialist reads them. Diagnosis are made and therapies are recommended or even Telehealth that involves psychiatric care, therapeutic relationships and other types of video conferencing. So when we go back to this idea about what other sources of disparities among rural veterans that really boils down to a lack of access and how you're going to make sure that they have access to subspecialty care and primary care for that matter. So in segment two, we've thought a lot about sub-segments of the veteran population, be it the homeless, be it those who have different racial and ethnic backgrounds, women versus men as we think about the potential causes of health care disparities.
