MEMORANDUM STATE OF ALASKA
Senate Committee on Veterans’ Affairs
Hearing on VA Health Care in Rural Areas
Brig Gen Deborah McManus
16 June 2010
I am truly honored I was invited to testify before the Senate Veterans’ Affairs Committee.
My first experience managing the complex issues regarding our Alaska National Guard (AKNG) members in remote Alaska was in 2006 when we were faced with mobilizing 600 soldiers in October for OPRERATION IRAQI FREEDOM (OIF). This was the largest AKNG deployment since WWII. At that time, I was the Director of Manpower and Personnel for the AKNG. We were faced with providing services to over 100 soldiers and their families from 26 remote Alaskan native villages throughout western Alaska. These soldiers were ready and anxious to serve in combat. They grew up as hunters with proven survivor skills. The 297th Regimental Crest worn by this Infantry Battalion displayed a Tlingit motto, Uyh Yek that translates to “Be on Watch. Ready to fire.” The challenge was preparing their remote communities and families for their 15-month absence. Ms Jan Myers, the Family Readiness leader was instrumental in this process. Before the deployment, we conducted a workshop in the village hub of Bethel. The AKNG sponsored the travel of soldiers and their families to ensure maximum participation. Among the entities represented were the Association of Village Council Presidents, faith leaders, Indian Health Services, state legislatures, TriWest, and local government. Issues included maintaining the subsistence lifestyle while many of the healthy males deployed, continuing use of Indian Health Services (IHS) ILO remote TRICARE since civilian practitioners were practically non-existent, and communication with families during the deployment since some did not even have phones or spoke English.
The next challenge became preparing for their return and ensuring access to veteran benefits in the remote native villages. In August 2007, only two months before the return of our rural veterans, a historic MOU was signed between the Alaska Veterans Affairs (VA) Healthcare and Benefits Administrations (VHA/VBA) and the Alaska Department of Military and Veterans Affairs (DMVA) to ensure access to the full spectrum of Veteran benefits with an emphasis on healthcare. Key goals included:
o Seamless Delivery of Healthcare Services to Rural Veterans
o Home Station Reunion and Reintegration Workshop for Returning GWOT Veterans to include Post Deployment Health Reassessments (PDHRA)
o Multidisciplinary Mobile Outreach Teams
The MOU was based are two primary assumptions: 1) Statistics reflected that up to 30-35% of returning Veterans will seek at least one psychological health visit within the first year after returning home. Such unresolved emotional disturbances as a result of a Veteran’s combat experience could be extremely detrimental to a small, remote Alaskan community; and 2) Due to lack of access to a VA facility for healthcare, rural Alaska Native Veterans will probably utilize the Alaska Tribal Health System.
The following initiatives were identified. Today, there is continuing progress.
o Telemedicine and teleradiology capability at 235 sites around the State and a multi-year home telehealth monitoring project through Alaska Native Tribal Healthcare Consortium (ANTHC).
o A VA Tribal Veterans Representative Program to train tribal representatives on VA policy, procedures, eligibility, and rules.
o A VA education program for the Alaska Tribal Health Organizations on VA eligibility and clinical information regarding Post Traumatic Stress Disorder and other Veteran readjustment issues.
o Vet Centers participation in outreach services.
o Coordination of access to care through flexible case management services that recognize the individual and family needs of veterans. These services or “pathways of care” would become a link of services that connect rural Alaska with Anchorage and Anchorage with Puget Sound.
o Work with state and federal agencies, civic organizations, and faith-based agencies to ensure a wide variety of benefits for Alaska Veterans. All agencies will identify key individuals and commit resources to address/work issues.
o DMVA will conduct Post Deployment Health Reassessments (PDHRAs) on-site vice a telephone or web-based format.
The Post Deployment Health Reassessments (PDHRAs) were vital in providing VA services to veterans returning from OIF living in remote western Alaska. We made it mandatory for these assessments to be conducted in-person in Anchorage to ensure access to a multi-disciplinary support team that included representatives from NGB, VHA, VBA, Vet Centers, TriWest, and Family Readiness. Since the soldiers were in an official status, their travel was sponsored by the AKNG. Our goal was to generate referrals to the maximum extent possible so the costs of further diagnosis and treatment at the Anchorage MTF were absorbed by the military. Typically, the seven permissible appointments were adequate to address those medical issues that presented themselves upon return from the deployment.
However, mental health problems may have a delayed onset or veterans delay seeking treatment. Reports on our OEF/OIF veterans document substantial mental health distress and adjustment difficulties among military personnel returning from combat operations in Iraq and Afghanistan. They are discovering problems with depression, Post-Traumatic Stress Disorder, and alcohol misuse are common particularly among National Guard and Army Reserve soldiers. Screening efforts to identify mental health concerns in the months following return from combat suggest that up to 42% of National Guard and Army Reserve troops require mental health treatment, but that relatively few actually get care (<10%). Many redeployed soldiers express concerns about interpersonal conflict (14-21%), highlighting the potential impact of war on the well-being of family members, as well as friends and employers. Why? The Reserves typically return to the civilian community and do not have the same access to military support networks. To better assist returning reserve veterans, many support programs have been developed. Typically, the AKNG has had to modify such programs to ensure outreach to the remote areas of Alaska.
In May 2005, the National Guard’s Transition Assistance Advisor (TAA) Program was initiated to assist Service members in accessing Veterans Affairs benefits and healthcare services to include obtaining entitlements through the TRICARE Military Health System and access to community resources. Mirta Yvonne Adams, the TAA for the AKNG brought 8 years TriWest experience to the position in addition to her countless years as a voluntary military spouse in Family Readiness groups. Mirta uses the AKNG integrated support network to better ensure seamless delivery for our Service members. This network includes the following services: education, Employer Support of the Guard and Reserve (ESGR), Military Funeral Honors, Yellow Ribbon Program, Military Family and Life Consultants, Survivor Outreach Services, Military One Source, Family Readiness, Chaplain, Director of Psychological Health, and Family Programs.
In 2008, the National Defense Authorization Act required the Secretary of Defense to establish a national combat veteran reintegration program to provide National Guard and Reserve members and their families with sufficient information, services, referrals, and proactive outreach opportunities throughout the deployment cycle. Although the AKNG had already established a well-functioning reintegration program, the four fulltime resources associated with the Yellow Ribbon program were a welcome addition. However, once again, funding for travel throughout remote Alaska was inadequate.
Providing veteran services throughout Alaska is extremely challenging. Alaska is #1 per capita of veterans in the nation, making up about 17% of the state’s population as compared to the national average of about 11%. The 2000 Census recorded our population to be 650,000 (now is ~686,300) with only two urbanized areas and 17 urbanized clusters. Out of 348 census localities, 52% have less than 250 people. Of the roughly 77,000 vets in the state, approximately 20% live in “remote” Alaska. I personally define remote as areas inaccessible by the road system with very small populations with very limited healthcare typically through an Indian Health Services (ISH) health aide.
In the first ever effort to personally connect with Alaska veterans in remote areas, the AKNG has funded a one-year temporary Yellow Ribbon Reconnecting Veterans Outreach Program at $500K to visit every BIA recognized village and incorporated city, visiting approximately 250 locations. The objectives are to locate and assist every veteran to apply for benefits they have earned from either the National Guard or the Veterans Administration, to assist families of deceased veterans apply for Veterans Headstones and Honor Guard Military Memorial Service, and to assist completing Alaska Territorial Guard applications. This team understands a veteran is eligible for government sponsored transportation to a VA medical facility upon receiving a disability rating of >30%, thus, they work diligently with veterans to complete the required paperwork. Village administrators have indicated a willingness to learn more about veteran benefits and the forms as well as ways to access the system. A report will be published in the October to November 2010 timeframe. Although this is the first program to have a significant impact in obtaining benefits for our remote Alaskan veterans, it will be expiring soon.
The Team Leader, Ms Alice Barr, M.Ed., LPC, LMHC, has shared tentative insights as listed below. In summary, the primary barriers to receiving benefits are communication (use of indigenous languages and reliance on the spoken word), obtaining ID cards, understanding/ completing paperwork, and access to healthcare.
o Negative reactivity to federal entities and their subordinates who may not understand or have the patience to deal with remote challenges such as language, finances, travel issues, and the accompanying emotional problems.
o The high cost of traveling to urban areas to seek medical care due to agency financial inability to “travel” the veteran in for care.
o The team has also encountered issues with those veterans who are not able to finance a trip into the nearest ID card facility. These members are having issues with their TRICARE entitlement, as they do not have a valid military ID.
o Education, home loan guarantee and SGLI/VGLI questions have also been a hit with these visits.
o Evidence of post war trauma in veterans who served in the Vietnam Conflict, Korean Conflict, Aleutian Campaign and OEF/OIF.
o Vietnam Vets are finally applying for benefits after years of personal neglect and who now find themselves riddled with the after affects of their service and accompanying Agent Orange complications while residing outside medical service areas.
o This team has encountered many female veterans – primarily National Guard, Navy, Air Force, and Army. Typically, the female veterans were afraid to report issues of gender discrimination, sexual harassment or assault due to their awareness that they would be stigmatized in the service and that their situations could in fact become worse. Many choose to serve their time and get out rather than make appropriate reports.
o Often, female veterans who did not think they deserved any benefits. They wanted to make sure that all the male veterans were in line first. Some of the female Veterans had injuries they kept quiet for so long a time and were now suffering very severe arthritis problems.
o Male and female veterans experience sexual trauma in their early lives. For some this impacts the way they experience and handle trauma as adults. For the Alaskan veterans this impact is doubled due to the lack of counseling services in their local areas.
o AKNG retirees and those within two years of their 60th birthday do not understand the how to apply for retirement benefits, the importance of the SBP, and converting from SGLI to VGLI to continue life insurance.
o Extreme dental problems secondary to remote living and lack of dental care.
o Economic problems stemming from the expense of remote living as well as lives as hunters and trappers in an effort to escape modern living.
The Alaska VA has fully partnered with the AKNG in seeking innovative solutions to serve our rural veterans. Recognizing the large number of AKNG OIF veterans in remote western Alaska, they established a Rural Veterans Liaison position in the Bethel “hub” last year. The liaison, Irene Washington, was perfect for the position. She had joined the active duty Army in 1979, transferred to the AKNG where she retired in 2005 and started working with the VA. Her military background and Yupik language enabled her to assist the regional veterans in understanding and obtaining the veteran benefits they had earned. Many had previously been receiving VA documentation in the mail and had never responded due to lack of understanding.
In July of 2009, a one-year VA pilot program went into effect to allow non-native veterans in remote Alaska to be provided healthcare through the Native Health Care network with VA reimbursement. This program involved seven remote census areas (Bethel, Dillingham, NW Arctic Borough, Cordova, Bristol Bay Borough, Nome, and West Hampton. Often, the Indian Health Services is the only provider in remote Alaskan locations. A report is anticipated within a few months after the program’s completion.
Additionally, the VA is extending medical facilities/services within the Great State of Alaska. A VA Outreach Clinic was opened in Homer in December 2009 using Kenai CBOC staff to provide services one day/week. Out of 582 veterans who live in this area, 328 are provided care through this clinic. A new VA Outreach Clinic in Juneau will open this fall with anticipation of eventually reaching veterans along the inter-island ferry system.
I also have the privilege to serve as the Alaska State Women Veterans’ Coordinator. As we know, women veterans are one of the fastest growing segments of the veteran population. Today, women comprise ~7% of the veteran population which is expected to be doubled in five years as a result of OEF and OIF. Within Alaska, the female population is actually 10%. Of the 8,250 women veterans within Alaska, approximately 16% are located in remote Alaska. In this position, I work closely with the Alaska VA’s Women Veteran Program Manager (WVPM). In 2008, VAs were funded for the WVPM to be a fulltime position.
In November 2009, the AKNG sponsored the first Alaska State Women Veterans Outreach Campaign at several locations on the more populated “road system”. At that time, VA statistics revealed only 3,000 or 36% of Alaska female veterans were enrolled with VA and only 1200 were using VHA services.
Like their male counterparts, many women veterans feel frustrated and disappointed by the complex bureaucracy of the Veterans Affairs health system. And, they are more reluctant to seek out the help of the Veterans Administration and utilize the benefits they’ve earned, possibly because of a lack of knowledge of their eligibility. This is especially acute when a veteran has suffered Military Sexual Trauma (MST). Once they finally gain the courage, they often feel victimized again when subjected to the cumbersome, impersonal process. I have a friend Andrea who was raped twice in 1987 while in the active duty Army and never reported it for fear of retribution. She retired from the Air Force Reserve in 2005 with 24 years of service. After attending the November 2009 Alaska Women Veterans Outreach Campaign, she finally sought help and was diagnosed as PTSD. When applying for compensation, she received a medical opinion that her PTSD most likely began due to abuse in childhood and adolescence and exacerbated by the two rapes. However, she characterizes her childhood as normal. Although she had not received her “rating”, she still felt victimized all over again. Nationally, we must simplify the application process for MST victims.
The Alaska VA has expanded women veteran services significantly over the past few years. Services now include:
o Fulltime Women Veterans Program Manager
o The Women Veterans Health Strategic Health Care Group sponsors a special campaign each month and the Alaska VA Healthcare System has been using the materials to promote the attention to women Veterans; monthly campaigns: August - Domestic abuse, September - Flu Prevention, October - Breast Health, November - Stop Smoking, December - Mental Health Awareness, February - Healthy Heart, March - Homelessness. For these campaigns, posters are printed and distributed to service areas, Vet centers and CBOCs. Poster displays are created for some of these in the lobby of the main Anchorage VA Outpatient Clinic.
o Provide written materials: Tri-fold describing services available to women veterans and a booklet with greater detail about services available to women Veterans.
o Conduct a monthly Environment of Care Assessment to ensure an environment in which women feel welcomed, safe and cared for.
o An active Women Veterans Advisory Committee composed of VA healthcare staff, Veterans Benefits staff, Vet Center, active duty military, OEF/OIF staff, Military Sexual Trauma staff, women Veterans Health Provider, and Women Veterans Program Manager, representatives from the 3MDG, and State Veterans Affairs Women’s Coordinator that meet monthly.
o September 11, 2010 – First annual Women Veterans Retreat to include keynote speakers, educational events, lunch, and a closing ceremony.
o Two Primary Care Providers (PCP) from the Anchorage VA Outpatient Clinic and one PCP from the Fairbanks VA Community Based Outpatient Clinic (CBOC) attended the VA sponsored Women Veterans Primary Health Care Mini-Residency in Seattle to improve their proficiency in women’s health care. More VA sponsored Women Veterans Mini-Residencies are planned for FY 2010 where PCPs from the Alaska VA will be able to participate.
o The Women’s Health Clinic at the Alaska VA expanded services to treat women with abnormal pap smear results rather than referral to non-VA providers.
o At the new VA clinic location in Anchorage which opened May 10, 2010, women veterans are able to come to the Comprehensive Care Clinic where they may receive Primary Care and Women’s Health Care from one PCP as well as evaluation and treatment by Social and Behavioral Health providers in an integrated clinic setting.
o Women’s Comprehensive Health Care Implementation Plan (W-CHIP) has moved ahead with PCPs at the Anchorage VA Outpatient Clinic, the Fairbanks VA CBOC, Kenai VA CBOC, Mat-SU VA CBOC and the VA Domiciliary for Homeless Veterans. Each of these locations has PCPs who are trained, interested and credentialed to provide comprehensive Primary Care and Women’s Health care to their patients.
o Basic benefits available to women include but are not limited to:
o Comprehensive Women’s Health Exams
o Contraception Counseling
o Bone Density Testing
o Maternity Benefits
o Gynecology Surgery
o Menopause Diagnosis
o Mental and Addiction Treatment
o Military Sexual Trauma Counseling
I sincerely appreciate this opportunity to testify before the committee. It is such a privilege and honor to serve our country and the state of Alaska.
DEBORAH C. McMANUS
Brigadier General, AKANG
Deputy Adjutant General - Alaska
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