When you think of the American Red Cross, what likely comes to mind is boots on the ground when hurricanes, earthquakes, and other natural disasters hit; international humanitarian relief efforts; blood drives; and CPR training courses. But a core part of its mission also is to support U.S. military personnel and their families. As such, the organization founded by Clara Barton more than 125 years ago has been a state-of-the-art partner in developing continuing medical education activities aimed at improving care for today’s military, National Guard, and Reserves as they return from active duty in Afghanistan and Iraq.
That’s what Bonnie Bixler, MEd, assistant director, continuing education, Penn State College of Medicine, in Hershey, Pa., discovered when she picked up the phone last year and found the American Red Cross’ Armed Forces Pennsylvania State Manager Margaret Pepe, PhD, JD, on the line with a unique proposition. Pepe wanted to develop an educational activity that would improve the screening and referral skills of the state’s primary care and mental health professionals so that they could better meet the needs of returning military service members who might be suffering from post-traumatic stress disorder or traumatic brain injury.
The two soon discovered it would take expanding the partnership to include a managed care company and Department of Defense health affiliates to pull off the activity they had envisioned. Here’s how they did it.
As someone whose job is to connect Red Cross programs and services with military organizations in the state, Pepe considered the need for the activity obvious. In a session at the 2012 Alliance for Continuing Education in the Health Professions, she explained that more than 2.1 million men and women have served in Operation Iraqi Freedom and Operation Enduring Freedom in the more than 10 years the U.S. has been at war. Many of these are National Guard and Reserves personnel, who return to civilian jobs when their rotations are completed. Pennsylvania has the largest contingent of National Guardsmen deployed during OIF and OEF—nearly 20,000.
Unlike in previous wars, most injuries incurred by those fighting in Iraq and Afghanistan come from improvised explosive devices and rocket-propelled grenades, which means that more returning military service personnel are coming back with PTSD and TBI than has been the case in the past. In fact, Pepe said, 22 percent of all returning service personnel have some form of TBI, and it’s estimated that one-third of troops suffer from PTSD when they return home.
And yet, particularly in the case of returning Guard and Reserve personnel who are known to their physicians in their civilian roles, when they go see their family doctor about recurring headaches, irritability, insomnia, and other classic symptoms of PTSD and TBI—things that also could have other causes—the doctor may not have the information needed to make the correct diagnosis. “PTSD and TBI have been recognized as common co-morbidities in this population. They’re the silent and often unrecognized signatures of these particular combats,” Pepe said.
Although the American Red Cross provides psychological first aid for military families that includes educational outreach to community healthcare providers and to the families of returning service members, it needed an accredited CME provider to provide the hook—the CME and CE credits—and the programming that would draw in the primary care physicians who most needed the education. So Pepe called Bixler at Penn State’s School of Medicine—which,in addition to being an accredited CME provider that was “practically in her back yard,” also was where Pepe earned her PhD—to develop a symposium that would help primary care and other healthcare providers better recognize and treat returning military service people with PTSD and mild to moderate TBI.
Bixler says that, while Penn State had worked with the military before, it hadn’t yet done anything on this specific topic. She was enthusiastic about the idea of using national partnerships with federal behavioral health agencies in Pennsylvania to benefit the state’s Guards and Reserves, and she got to work right away drafting up a budget.
However, being a self-sustaining CME department that must cover all direct costs involved with an activity, “We quickly realized that there was going to be a shortfall,” Bixler says. So she and Pepe thought about potential funders who would also have a vested interest in serving this community of providers to improve the lives of returning military and their families.
The answer they came up with was Health Net Federal Services LLC, the managed care support contractor the Department of Defense uses to provide civilian sector physical and behavioral healthcare services to nearly three million active and retired National Guard/Reserve members and their families who live in the 23 states that make up the TRICARE North Region, including Pennsylvania.
According to Health Net’s medical director, Joyce Grissom, MD, “It was a natural fit for us. We were happy to pitch in some financial support and to have the opportunity to inform them about the TRICARE benefit and VA benefits.”
This is particularly important in Pennsylvania, she says, where returning guard and service members are “geographically challenged” when it comes to getting care in a DoD or VA facility, since they are few and far between in the state. “We wanted to work with nonmilitary care providers to meet their needs,” she says.
The partners decided to create a one-day symposium that would be held four times in 2011 in western, central, and eastern Pennsylvania. The mainly didactic program included morning presentations on the etiology, assessment, and treatment of PTSD, followed by information on TBI screening and symptom management for the military, dealing with co-occurring TBI and PTSD, and how to help returning service members reintegrate into their families and communities. “Because we thought primary care would be our main audience, we focused on assessment and treatment,” says Bixler.
But first they had to find speakers who could address the topics in a military-specific way. As they began their research, two strategic partners rose to the top of their list: The Department of Defense Center for Deployment Psychology, and the Defense and Veteran’s Brain Injury Center. Bixler’s organization had recently had a
The design of the activity was a group effort, stresses Bixler. Grissom adds, “We were totally in agreement with the sourcing of the speakers. Part of the core mission for both of the organizations is training healthcare providers.” Bixler adds that Health Net and the Red Cross were instrumental in providing the data demonstrating the need for this type of education in Pennsylvania to improve the screening of returning military for PTSD and mild to moderate TBI.
Grissom rounded out the day with a closing session on the resources the military and the VA make available to both returning military service men and women and those who provide care for them.
To help draw the medical and behavioral healthcare providers that they wanted to come to the symposia, Bixler was able to provide American Medical Association Physician Recognition Award Category 1 credit for physicians, psychiatrists, and others with medical degrees; American Academy of Family Physician credits for the primary care providers; Pennsylvania State Nursing Association credits for nurses; and American Psychological Association credits for the therapists, behavioral counselors, and marriage and family social workers.
Bixler says that, though her office does provide an annual social work conference and other activities with APA credit, most of what they offer targets mainly primary care and other physicians, so that was her main concentration in the symposia. “We did what we could with the behavioral and mental health folks, but we relied more on Health Net and the Red Cross because of their strong ties to those professions,” she says.
Because the Red Cross works closely with mental health professionals who their services during natural disasters, it wasn’t a reach for that organization to spread the word to those disciplines, says Marjorie Kukor, PhD, senior associate, mental health, Service to the Armed Forces, American Red Cross, who took over the symposia-planning duties after Pepe retired from her official capacity with the Red Cross earlier this year. Among the many organizations to which the American Red Cross sent electronic invitations were the local hospitals and insurance companies, and health/behavioral health and professional association contacts.
Health Net reached out to its networks of specialty and primary care providers through e-mails and fax blasts, and all involved put notices on their Web sites and asked partnering organizations to do the same on their Web sites and listservs. Health Net also issued a press release on the symposia and used its legislative liaison channels to spread the word.
They also kept the pricing “low enough to be attractive compared to other offerings, but high enough to prevent excessive no-shows,” says Bixler. This strategy worked well—there were very few who signed up who didn’t actually come to the symposium.
In the end, they attracted a total of more than 250 participants to the four symposia. While the aim was to bring in both primary care and behavioral health providers, “What we found was that this was far and away of greatest interest to those on the behavioral side, which ranged from behavioral health nurses to licensed clinical social workers and psychiatrists,” says Grissom. More than half were master’s degree–level behavioral health professionals, with a good smattering of nurses, psychologists, physicians, and physician assistants. About one-third of participants had a relationship with TRICARE.
The organizers did immediate post-activity evaluations and followed up with a six- to 12-month post-activity survey. As Grissom points out, they knew that a one-day course wouldn’t make participants accomplished cognitive behavioral therapists—the point was more to provide an introduction to PTSD and TBI for returning military personnel, and to show how to get more detailed military-specific training on the topic.
The results showed that it helped build awareness of the signature characteristics of the PTSD and TBI that service members returning from Iraq and Afghanistan are suffering from—83 percent said they gained new strategies in the immediate post-activity evaluation. More than half said they planned to implement those new strategies. In the follow-up survey, which got a 39 percent response rate, 38 percent said they used screening tools for PTSD more than they had previously, and 23 percent said they used TBI screening tools more often.
Getting physical and behavioral healthcare providers to ask new patients if they have a military deployment history sounds simple, but it’s important, says Grissom. If they don’t know someone was exposed to an IED blast while deployed, HCPs may not connect nonspecific issues such as sleep, anger management problems, and headaches to a PTSD or TBI diagnosis.
Twenty-nine percent also said in the follow-up survey that they had changed their referral habits, including more referrals for medical testing, and more referrals to neuro and for brain MRIs. Among the strategies they reported implementing post-symposium were asking clients about their military background and if they had been injured in ways that could cause TBI (41 percent); improving their assessment of PTSD/TBI co-morbidities (32 percent); screening for blows to the head and consulting with spouses and partners about behavior issues (32 percent); using behavioral techniques for dealing with troubling dreams (29 percent); increased use of TBI and PTSD assessment tools (27 percent), and treating nightmares (23 percent).
While the symposia did not attract the number of primary care practitioners the partners hoped for, it was still considered a success. Keeping in mind lessons learned during the 2011 series, they relaunched the symposia in 2012 to cover an expanded geographical area. The first, held in July in Arlington, Va., attracted about 100 participants. They are headed to Watertown, N.Y., and New York City in the fall, and to Dayton, Ohio, in November. “We covered Pennsylvania pretty thoroughly in 2011, so we used the Red Cross and Health Net data to pinpoint concentrations of post-deployed Guards and Reserves to determine where to take it next,” says Bixler.
One change for 2012 was to bring in the DoD’s National Center for Telehealth and Technology, also known as T2, which along with DVBIC and the Center for Deployment Psychology falls under the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. T2’s addition to the program includes online technological resources
and applications for those who need help with self-managing issues such as sleep problems.
There’s also a program that uses avatars to help people address their combat experiences, as well as online resources for the families of returning military, and apps to help those on the provider side do things like manage mild TBI. “We’ve seen them demonstrate these resources at other meetings, and we invited them to send a presenter this year; we invited participants to bring their smartphones and tablets so they could be walked through the various resources and apps,” says Grissom.
“We’re starting now to focus on not just raising awareness of the issues,” says the Red Cross’ Kukor, “but also what resources are available and what participants can do to learn more.”
While the program received high marks from the primary care physicians who did attend, the problem of getting more of them to come remains. The partners wonder if the one-day seminar format may be a sticking point for this particular audience.
“They need recognition and screening strategies and first-stop management strategies for mild TBI, which is less than what the behavioral health side needs on the topic,” says Grissom. The idea is to streamline the information this type of participant needs into a one- or two-hour session that can be offered as part of other educational events that primary care physicians already attend, or perhaps as a webinar or some other type of online offering.
“We’re looking for more ways to work with our partners,” Grissom says, “especially the Center for Deployment Psychology, because the behavioral interest is so high. We’ll complete the four symposia we have scheduled for this year, then see where we can most usefully take it from there.”
Kukor adds, “We likely will be looking at how we can be a funnel to make what’s out there more useful to the majority of mental health and primary care providers to give them direction once they have awareness of the issues. It might mean adding specific topics; it might mean more collaboration, depending on the feedback we get and what the professional literature says.”
“We do know there is a lot of need, and that people who need help may not be close to a military or VA facility that can assist them,” Grissom points out. “So a community-based approach to meeting their needs is something that needs to be developed more robustly to provide the best and most compassionate services to these folks and their families.”
Read the Sidebar: What We Learned from Our Experience