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Letter to the Editor

Legislative: Providing Veteran-Specific Healthcare

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Jillian Weber, MSN, RN, CNL
Angela Clark, PhD, RN

Citation: Weber, J., Clark, A., (May 18, 2016) "Legislative: Providing Veteran-Specific Healthcare" OJIN: The Online Journal of Issues in Nursing Vol. 21 No. 2.

DOI: 10.3912/OJIN.Vol21No02LegCol01

There are currently 22 million veterans living in the United States. While 8.92 million veterans are enrolled in the Veterans Administration (VA) Health Care System, nearly 60% of veterans are relying on services outside the VA system (National Center for Veterans Analysis and Statistics, 2014). As such, it is imperative that civilian nurses understand service eligibility and veteran-focused care for this unique population.

It is a common misconception that all veterans are eligible to receive full healthcare benefits within the Veterans Health Administration (VHA). However, veterans are only eligible for health benefits if they meet specific requirements, such as certain minimum lengths of service and type of discharge as described below (Szymendera, 2015). Due to the specificity of these requirements, as well as the complicated eligibility process for receiving care in the VHA system, less than half of veterans receive healthcare services within the VHA system (National Center for Veterans Analysis and Statistics, 2014). Health disparities among this population have been well documented (Montgomery, Dichter, Thomasson, Roberts, & Byrne, 2015). Additionally, with the introduction of the Veterans Choice Act in 2014, veterans increasingly are accessing civilian healthcare services (VA, 2014).

Today nurses are at the forefront of the healthcare delivery system and are often the first to provide services to veterans. As nurses, we must be prepared to assist veterans in determining eligibility and understand how to help veterans navigate the VA system, so as to increase their access to care. A better understanding of this process can ensure high quality, veteran-specific patient care, and potentially decrease the health disparities within the veteran population.

Determining Veteran Status and Eligibility

The VA offers a variety of benefits to veterans of the armed forces, including multiple types of financial assistance, healthcare, housing, and education (Szymendera, 2015). To be eligible for benefits, a former service member who enlisted after September 8, 1980, must have served a minimum of twenty-four continuous months of active duty. There are no minimum service obligations prior to this date. However, health benefits for injuries incurred during active military service (service-connected disability) are exempt from this service obligation (Szymendera, 2015). Discharge criteria require that an individual be released from military duty with either an honorable discharge or general discharge (Moulta-Ali & Panangala, 2015). Although a dishonorable discharge automatically disqualifies an individual for VA benefits, other-than-honorable discharges or bad conduct discharges can be determined by special consideration (Moulta-Ali & Panangala, 2015).

Once former service members are determined eligible for benefits, their healthcare services are provided under a component of the VA called the Veterans Health Administration (VHA). The VHA is an integrated health system comprised of VA medical centers (VAMCs), community based outpatient clinics (CBOCs), community living centers (CLCs), Vet centers, and domiciliaries across the United States (VA, 2016). Veterans can receive a variety of services including primary care, specialty care, mental healthcare, and rehabilitative services. In response to both the growing need for increased veterans’ healthcare services and the rather recent whistleblower activity related to lengthy appointment wait times for veterans, the Veterans Choice Act was implemented in 2014. The Choice Act directs the Veterans Choice Program; this program allows for VA eligible veterans to receive non-VA care if they have to wait more than thirty days for VA care or if they live more than forty miles from the nearest VA medical facility (VA, 2014).

Veteran-Specific Health Needs

Today, in the United States, there are veterans seeking healthcare services who served during wartime and peacetime and from every major conflict since WWII. Each service period has differing characteristics affecting patient care services and health outcomes. For that reason, nurses must be extremely cognizant of the differing eras and varying effects of military service on the health of veterans. In general, veterans are exposed to hazardous materials that can be harmful to their health, including contaminated water, heat stroke/exhaustion, cold injuries, nerve agents, pesticides, endemic diseases, sand, dust, smoke, radiation, noise, fuels, asbestos, and industrial solvents (VA, 2015b). More information and a complete list of potential exposures can be obtained at the following website [http://www.publichealth.va.gov/exposures/index.asp].

Table

Military Era

Time Period

Health Exposure Concerns

WWII

12/1941-12/1946

Chemical warfare agent experiments, cold injuries, nuclear weapons testing

Korean Conflict

6/1950-1/1955

Cold injuries, hepatitis C, nuclear weapons testing, agent orange exposure

Vietnam

8/1964-5/1975

Agent orange exposure, cold injuries, hepatitis C

Persian Gulf War, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), & Operation New Dawn (OND)

8/1990-Date determined by presidential proclamation or law

Animal bites, burn injuries, blunt trauma, shrapnel, spinal cord injury, traumatic amputation, traumatic brain injury, mental health issues, chemical/biological agents, immunizations, and infectious diseases

(Table developed by the authors based on information from Szymendera, 2015 and VA, 2015b)

It is vital for nurses and other healthcare providers to not only understand the environmental exposures that veterans often suffer during service but also the psychosocial characteristics of the time period in which an individual served (See Table). For example, research has shown that Vietnam veterans suffer disproportionately, as compared to veterans who served during WWII and the Korean War (Fontana & Rosenheck, 2008; Villa, Harada, Washington, & Damron-Rodriguez, 2002). Vietnam veterans have reported both exposure to a greater number of atrocities and more difficulty with activities of daily living than have WWII veterans. They are also more likely to be diagnosed with post-traumatic stress disorder (PTSD) than veterans from the Gulf War and have higher rates of drug abuse compared to Iraq/Afghanistan veterans (Fontana & Rosenheck, 2008). The culture of the Vietnam War was different from that of other military time periods due to the unpopularity of the war in America, the large number of casualties, and use of conscription (in place of an all-volunteer force).

Veterans from the current conflict in Iraq and Afghanistan suffer from higher rates of PTSD than their Gulf War counterparts; yet they have the advantages of being younger, more likely to be working, more often married, and less likely to have a history of incarceration (Fontana & Rosenheck, 2008). Hence, veterans from the current war are often capable of socially integrating themselves back into society, which gives them a health-related advantage over veterans from previous wars. However, there is still much to be understood about the effects of the current war in Iraq and Afghanistan on the lives and health of veterans returning from this war since the conflict remains ongoing.

Some other health-related conditions among veterans that nurses need to know about include mental health conditions, such as suicide risk and substance use disorders (Kelsall et al., 2015); traumatic brain injury and women’s health issues (Kimerling et al., 2015, Miller & Ghadiali, 2015); depression, pain management, reproductive health, coping with chronic general medical and psychiatric conditions, sleep problems, weight management, posttraumatic stress disorder (PTSD) and homelessness (Kline, Callahan, Butler, Hill & Losonczy, 2009; Tsai & Rosenheck, 2015).

Conclusion

Because nurses represent the largest healthcare profession and work in a wide variety of locations and healthcare settings, they are likely to encounter some of the 22 million veterans living today. In order to provide high quality, comprehensive, and veteran-focused care, we encourage nurses to ask the following questions:

  1. When and where did you serve?
  2. What was your job while serving?
  3. How has military service affected you?

These questions have been developed by the Department of Veterans Affairs (2015a) for clinicians to use in practice. They provide clear direction for assessing a veteran’s health needs and guide nurses in providing the most optimal health outcomes. Being informed about veterans and their health needs should be a priority for all nurses. Learning about the health needs of veterans enables nurses to promote desired health outcomes among veterans and to positively contribute to their overall quality of life. It’s important that as nurses we diligently serve our veteran population, just as they have served us.

Authors

Jillian Weber, MSN, RN, CNL
Email: jacobji@mail.uc.edu, jillian.weber@va.gov

Ms. Weber is a PhD candidate and a Jonas Veterans Healthcare Scholar at the University of Cincinnati College of Nursing in Ohio. She received her BS in biology from Coastal Carolina University in Conway, South Carolina and her MSN in nursing with a certification as a clinical nurse leader from Xavier University in Cincinnati, Ohio. Jillian has been working at the Cincinnati VA Medical Center for almost nine years. Her current position is a staff nurse in the emergency department; however, she has previously worked as a clinical nurse leader on inpatient units. Ms. Weber’s dissertation is focusing on chronic disease management among veterans who are homeless. She works to advocate for this vulnerable group, and for all veterans, so as to improve their access to care and the quality of care they receive both within the VA system and in the community.

Angela Clark, PhD, RN
Email: brangieclark@gmail.com

Dr. Clark is an Assistant Professor at the University of Cincinnati College of Nursing in Ohio. She received her BSN and MSN degrees from the University of Tennessee (Knoxville) and her PhD from the University of Cincinnati. She has had extensive experience providing nursing care in community settings. Much of her clinical experience has focused on the identification and treatment of at-risk communities and individuals. Dr. Clark remains a committed advocate for the public’s health, and effectively promotes optimal outcomes to mitigate health disparities using harm reduction strategies. Her primary research concentration focuses on addiction.

References

Fontana, A. & Rosenheck, R. (2008). Treatment-seeking veterans of Iraq and Afghanistan: Comparison with veterans of previous wars. The Journal of Nervous and Mental Disease, 196(7), 513-521.

Kelsall, H.L., Wijesinghe, M.S.D., Creamer, M.C., McKenzie, D.P., Forbes, A.B., Page, M.J., & Sim, M.R. (2015). Alcohol use and substance use disorders in gulf war, Afghanistan, and Iraq war veterans compared with nondeployed military personnel. Epidemiologic Reviews, 37(1), 38-54. doi: 10.1093/epirev/mxu014

Kimerling, R., Bastian, L.A., Bean-Mayberry, B.A., Bucossi, M.M., Carney, D.V., Goldstein, K.M., …& Frayne, S.M. (2015). Patient-centered mental health care for female veterans. Psychiatric Services, 66(2), 155-162. doi: 10.1176/appi.ps.201300551.

Kline, A., Callahan, L, Butler, M., Hill, L., & Losonczy, M.F. (2009). The relationship between military service eras and psychosocial treatment needs among homeless veterans with a co-occurring substance abuse and mental health disorder. Journal of Dual Diagnosis, 5, 357-374.

Miller, L.J., & Ghadiali, N.Y. (2015). Gender-specific mental health care needs of women veterans treated for psychiatric disorders in a veterans administration women’s health clinic. Medical Care, 53, S93-S96. doi: 10.1097/MLR.0000000000000282.

Montgomery, A.E., Dichter, M.E., Thomasson, A.M., Roberts, C.B., & Byrne, T. (2015). Disparities in housing among veterans with general medical, cognitive, and behavioral conditions. Psychiatric Services, 66(3), 317-320. doi: 10.1176/appi.ps.201400014.

Moulta-Ali, U. & Panangala, S.V. (2015). Veterans’ benefits: the impact of military discharge on basic eligibility. Congressional Research Service. Retrieved from: https://www.fas.org/sgp/crs/misc/R43928.pdf

National Center for Veterans Analysis and Statistics. (2014). Department of veterans affairs statistics at a glance. Retrieved from http://www.va.gov/vetdata/index.asp

Szymendera, S.D. (2015). Who is a “veteran”?- Basic eligibility for veterans’ benefits. Congressional Research Service. Retrieved from https://www.fas.org/sgp/crs/misc/R42324.pdf

Tsai, J., & Rosenheck, R. A. (2015). Risk factors for homelessness among US veterans. Epidemiologic Reviews, 37(1), 177-195. doi: 10.1093/epirev/mxu004.

United States Department of Veterans Affairs (2015a). Military health history: Pocket card for clinicians. Retrieved from http://www.va.gov/oaa/archive/Military-Health-History-Card-for-print.pdf

United States Department of Veterans Affairs. (2015b) Public health: Military exposures. Retrieved from http://www.publichealth.va.gov/exposures/index.asp

United States Department of Veterans Affairs. (2014). Veterans access, choice and accountability act of 2014 (Choice Act). Retrieved from http://www.va.gov/opa/choiceact/documents/choice-act-summary.pdf

United States Department of Veterans Affairs. (2016). Veterans health administration. Retrieved from http://www.va.gov/health

Villa, V.M., Harada, N.D., Washington, D., & Damron-Rodriguez, J.D. (2002). Health and functioning among four war eras of US veterans: examining the impact of war cohort membership, socioeconomic status, mental health, and disease prevalence. Military Medicine, 167, 783-789.


© 2016 OJIN: The Online Journal of Issues in Nursing
Article published May 18, 2016

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