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Military and veteran

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Military and veteran

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Content Running head: MILITARY AND VETERAN 1
Military and Veteran
Capstone Project Assessment
SOWK 722
Adam J Castro, MSW, DSW
Candidate Residency 2
October 29, 2019
Dr. Ron Manderscheid, PhD
Doctor of Social Work
conferral: 2020 May
MILITARY AND VETERAN 2
Abstract
This paper will focus on the military and veteran community. The focus is on how
technology can be leveraged to provide care with the veteran community. Some of the limits that
impact the veteran community with access to care will be indicated. The innovation leveraging
technology will be used to decrease barriers with access to mental health care. There will be
further discussion with how technology can be used to address gaps in services.
GC: Harness Technology for Social Good & Close the Health Gap
Problem Statement: policies and stigma that act as barriers for AMSM and Vets that keep
them from accessing preventative and stabilizing care.
Area 1. Executive Summary
Project and Grand Challenge
This Capstone Project focuses on the Grand Challenge of: Harness Technology for
Social Good and Close the Health Gap. The social work profession is encouraged to engage in
the use of technology that is responsive to address the gaps in the field that has implications for
vulnerable populations that are served. The use of technology has the potential to serve those
who encounter barriers with access to services. This innovation will also address the existing
barriers that limit the necessary resources. (Grand Challenges for Social Work, 2018). This
innovation that will be used with the Fresno Vet Center is intended to serve those who have
served our country. The technology will serve as a pilot program that is expected to enhance the
veteran experience with decreasing barriers to mental health services.
Active military service members (AMSM) as well as Veterans (Vets), who have the
greatest need for mental health support often encounter the greatest barriers engaging in
treatment. There is often a perceived stigma that service members experience who are likely to
MILITARY AND VETERAN 3

have a mental health condition (Varga, Haibach, Rowan & Haibach, 2018). However,
individuals will overcome the barriers associated with mental health stigma if there is a positive
experience with engaging mental health services in the military (Varga, Haibach, Rowan &
Haibach, 2018). A positive experience engaging mental health services is likely to have a
positive impact on their life going forward that can reduce barriers with accessing care. The more
opportunity a person must engage in services it can increase awareness with existing resources
and reduce potential fears with help-seeking (Varga et al., 2018) for AMSM and Vets, help-
seeking early can influence behavior engagement with the VA. This innovation has the potential
to reach service members and change outcomes for them through a positive experience.
The operation tempo of the military and the continuous conflict that increase the chances
of a deployment to the combat zone will require more support for the military population. Over
one-third of the service, members have been deployed two or more times in support of the Iraq
and Afghanistan conflict (Wilson, Gettings, Hall, & Pastor, 2015). Approximately 2.5 million
service members have deployed to the combat zone (Wilson et al., 2015). The repeated
deployments not only place stress on the service members but families as well. This exposure
increases the risk of unhealthy coping skills that can result in misconduct, addiction, or legal
issues for the individual serving in the military.
Purpose of Project
This innovation is intended to support those who are currently serving in the military and
the veteran community by increasing access to mental health support, through the use of
technology that will reduce the barriers of initiating services, obtaining verification for
eligibility, reduce the time between intake, diagnoses and referral and actual connecting with a
therapist. Additionally, the use of technology within a federal agency can engage the military and
MILITARY AND VETERAN 4

veteran population across state and international lines. This innovation has the potential to
change outcomes for AMSM and Vets. There is much potential for innovation beyond the pilot
at just one Vet Center if adopted on a larger scale. A strong Vet Center system will be a way to
address the gaps in policies in the military with mental health.
It is very common that a mental health provider in the military to be accountable for
treatment and the mission. There are times that a Psychologist will be put in a situation to make
recommendations that go against the wishes of the service member who is the client receiving
treatment in support of the military mission (Johnson, Grasso, & Maslowski, 2010). With the
military mental health providers needing to put the mission first, and regard for safety it creates
an additional barrier to receiving care. This creates a problem for a service member who may
feel the need to talk to a mental health professional. The fact that a service member may risk a
career for discussing mental health is often something that creates a barrier with help-seeking.
The culture of the military service with pride and masculinity is just a layer that contributes to
the avoidance of the need to be vulnerable. The Vet Center system has a way of affording
confidentiality to the service members who engage in services.
It is often that service members experience leaders that do not support help-seeking in the
military. Service members are often at risk for charges of malingering or discharge for mental
health reasons when advocating for mental health services. The military would be able to afford
more protections for service members when it comes to mental health if there were some form of
legal partnership, but that is not the way the military is structured. There are certain mental
health conditions, such as the personality disorder diagnosis that would result in separation from
military service with a reduction in veteran benefits (Shonk, 2017). There are several layers that
create limits for service members with access to mental health. The military readiness that needs
MILITARY AND VETERAN 5

to be maintained in the service creates policies that create barriers to help-seeking. Having
resources that reduce risks to a career in the military could increase participation of those in the
military with their individual wellness. The Vet Center would be in a good position to provide
care with addressing these limits with non-traditional business hours and the use of technology
all the while with keeping the record confidential.
At some point, everyone gets out of the military regardless of the amount of time served.
Serving in the military is a unique experience that has a beginning and an end. Some of the
experiences or habits that are associated with military experience result in poor decision making.
This can result in misconduct and criminal charges of post-military experience. The criminal
justice system is not equal in handling the care of veterans brought up on criminal charges (Lee,
2013). The vets that experience PTSD symptoms may use alcohol to manage symptoms and may
also have thrill-seeking behaviors that may get them into trouble with the law. Those who
experience the harming of innocent people in the combat zone might experience moral injury
with an increased risk of violent behavior and recreating a similar scenario with the potential for
domestic violence (Lee, 2013). With the continued combat operations and the concern that the
general public has for the military service members returning home resulted in the Veteran
Treatment Court (VTC). The Veteran Treatment Courts were established as a diversion program
that focuses on treatment over incarceration with the involvement of the VA. This innovation
using technology could create a stronger alliance in support of reducing incarceration risk factors
by increasing access and options for care. Seeking help from the VA, and other community
resources could have their own unique logistical barriers. A transportation issue could be the
difference in compliance with Veteran Treatment Court goals for the veteran. The use of
technology with the Vet Center would reduce logistical barriers and support existing programs.
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Innovation and Impact
Soldiers who were hospitalized for a mental health condition were more likely to be
involuntarily separated from service than any other medical issue. Approximately 45% of
soldiers who received a mental health diagnosis separated from the service within 6 months post-
discharge from psychiatric hospitalization in 1998 (Hoge et al., 2005). There is a connection
with medical discharges and mental health diagnoses that were associated with military
experience (Hoge et al., 2005). With service members getting separated from the military from
mental health it continues to create barriers with help-seeking. Furthermore, it discourages
service members from seeking mental health services when there are negative consequences for
an individual’s career. There is a difference between command support, medical
recommendations, and policies in the military when it comes to readiness for the service. This
innovation is intended to address the gaps in policies and increase access to mental health
services.
The current conflict with Iraq and Afghanistan has been more of a working-class war
than any other previous conflicts. These people who are getting killed or wounded in the current
conflict are more likely to come from a lower socioeconomic status than those who have served
in previous wars. Those who enter the service with reduced resources and leave with similar
increases the risk for mental health problems (Kriner & Shen, 2016). The stress sensitization
theory would suggest that a negative childhood experience would increase the likelihood of
mental health issues as an adult. There is a strong connection with adverse childhood history and
mental health outcomes later in life for those serving in the military. With the high reporting
numbers of service members already entering the military with a complex background, it feeds
into the high rate of suicides with the military population. The service members that may have
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had childhood trauma were more likely to be more vulnerable to experiencing mental health
problems (Bandoli et al., 2017). The military and veteran population have a significant need for
more resources. This innovation is a way to provide early intervention to service members using
technology that can set the person up for transitioning out of the military and reduce individual
risk factors. Those who have served and supported the post 9/11 conflict deserve the very best in
resources and opportunities available to them. This is especially important as this group who has
served is likely to have suffered severe hardships prior to serving in the military.
There are similarities when comparing society with college students to some of the limits
and risk factors to the military community. It has been found that those who attend college could
experience mental health issues and that they are likely to not be aware of services available to
them through the college (Johnson & Kalkbrenner, 2017). It is concerning that these barriers
exist in college as some of these students might go on to serve in the military eventually, or
already have served. Those who attend college post-military service could increase awareness if
receiving support prior to exiting the military. This innovation has the potential to reduce barriers
with mental health services in the military and prepare the individual for transition into civilian
life.
Specific Problems and Issues for Military Population
Even though a military mental health professional can have a reduced risk of exposure to
combat-related risk. They are not exempt from some of the similar stressors that are universal to
the uprooting of the norms that he, or she might be accustomed to in their daily lives. The effort
to have military mental health professionals near the combat zone is designed to help service
members cope with combat stressors, and return home (Miller & Warner, 2013). The providers
and those performing other tasks had similar symptoms associated with their deployment
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experience. Over 80% of the mental health professionals had difficulty readjusting after
returning home (Miller & Warner, 2013). Approximately half of the mental health providers
experienced a sense of detachment and had a hard time with experiencing joy in their work
(Miller & Warner, 2013). There were similarities in the reactions that the mental health
professionals were experiencing as those with different military occupations (Miller & Warner,
2013). These experiences with combat have a universal similarity, and it is concerning that even
professionals in the mental health field are negatively impacted. If a professional is coming back
having trouble, then it is likely that those who are in more of a combat role to be more severely
impacted. It is possible that the senior leadership in the military is experiencing barriers with
seeking care themselves. This is extremely troubling when those who were put in place to care
for others must suffer along with others as they struggle with their own internal problems while
at the same time providing treatment. The military environment has a different set of rules and
regulations that differ from the civilian environment.
Mental health services look different in the civilian sector than what is provided in the
military. The civilian sector with mental health has more protection with confidentiality than
those who are in the military. In the service, a mental health provider may be required to submit
a client’s progress, and this what makes military service health resources different than the
civilian sector (McKinzie, 2017). If the military treated mental health like physical health in the
service this would allow for appropriate referral with the treatment plan (Fischer & Weisner,
2019). With limited confidentiality due to the nature of the military and mission readiness, this
creates a barrier with help-seeking. The challenges that the military faces with engagement in
medical, and mental health services come back to policies that serve the system at large. There is
MILITARY AND VETERAN 9

most likely limited knowledge in the civilian sector on how there is some level of risk to the
service member for accessing care.
The consensus from leaders in the military expect for junior personnel to get past their
mental health concerns. It is very common in the military for the behavioral health side to have
differences with leaders in operational departments. Often, the behavioral health side has a
different vision for the wellbeing of their clients while commanders are trying to get that same
individual who is receiving treatment to be ready for the mission. This issue comes down to that
behavioral health and commanders have different missions that do not align with each other.
Even though the Army had made progress with making mental health a priority there was still a
problem with getting mental health and other departments to work together as they each had a
conflict with their separate goals (DiBenigno, 2019). With mental health providers and
commanders with different wishes, this places the person receiving treatment in the middle. This
can be very intimidating, and anxiety evoking for the individual who needs support. When cases
are handled inappropriately this sends a message to other service members and makes it seem
that seeking care is not worth it for them when their peers could be potentially harassed at many
levels when they are experiencing their most vulnerable moments.
The military has made recent efforts with the use of a mental health video to engage
service members with what an intervention can look like for them. This was an attempt to
increase help-seeking behavior and normalize the process. This video was intended to also
educate military leaders about seeking mental health services (Suzanne et al., 2019). The fact
that the military is using a mental health educational video to promote help-seeking could be in
response to the high rate of suicide that the military has been experiencing. It is unclear if the
video will bring about the change that is needed for mental health in the military community.
MILITARY AND VETERAN 10

Projects Connection with Policy and Practice
With the implementation of the VA Mission Act of 2018, it will combine VA medical
services and community care in the same budget for 2019. This was done in response to reduce
the suicide risk for the veteran community. The VA expects to expand the partnership with
community care providers to reduce wait times and provide care to those who are transitioning
out of the military. This expansion of private care resources will give the veteran community
better access to care especially of those who are 40 miles, or more from the nearest VA facility
(Pyne et al., 2019). Just as the greater VA seeks to reduce logistical barriers, so does this
innovation by using technological advances by using telehealth VTC technology to deliver care
from the Vet Center to the military community. The use of technology from the Vet Center will
be a way to provide care to service members across state lines who experience logistical and
policy barriers with accessing care.
Methodology and Tools
The Vet Center innovation will seek to reduce wait times and provide innovate ways to
engage the consumer using technology. The use of Video Teleconference capabilities (VTC)
capabilities will allow the consumer to meet with a mental health provider on a digital screen in
the facility, or online. The Vet Center already uses a form of Artificial Intelligence (AI) for data
tracking and documentation that will be continued to be used. The Vet Center data will be
collected and analyzed with innovation compared to traditional treatment methods. There will be
a prescreening for those who consume services to assess for a potential crisis that is web-based,
and a post-screening questionnaire for the consumer as well to rate the quality of engagement.
The feedback from providers and consumers will provide valuable feedback with the
intervention. The intention is to collect information on those who access care, and how to best
MILITARY AND VETERAN 11

serve the target population. All the remote clinicians will have a Memorandum of Understanding
(MOU) to access RCS Net for continuity of care with documentation within the Vet Center
System.
This change in policy and practice has the potential to make a large-scale impact. The
goal is to have a successful Vet Center pilot program. Then take the concept to scale by
implementing into other Vet Center facilities. The partnerships with other clinicians that will
work remotely will save on office space and overhead costs that are associated with the delivery
of traditional in-person treatment methodologies that are more of the norm when it comes to
mental health services. The main cost associated with using technology as a service to provide
mental health will be personnel costs for the clinician's salary. As the Vet Center operates as an
extension of the greater VA health care system much of the technological resources will be done
in kind as a part of the collaborative partnership.
Furthermore, the clinicians that will be used specifically for the innovation will require
some training with how to use new and existing tools for the Vet Center. It is estimated that the
training process for a clinician to receive the necessary training would take approximately two
weeks. A familiarity with the existing Vet Center RCS program will be necessary for the
documentation of a client chart. The new website that will be used with the host pilot site will
require training for the new clinicians for the innovation. This website for the Vet Center pilot
host site will allow the remote clinician to be notified when there is a potential client. All
attempted contacts remotely will be tracked as a way to co follow-ups if necessary.
The independent website for the hosting Vet Center will allow consumers to make
contact directly. The ability for a consumer to upload forms electronically encrypted will be
available to meet the Vet Center requirements. There will be secure messaging with admin staff
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for questions and answers who can also assist with any concerns with eligibility. The consumer
will be able to click a link for mental health providers once cleared prescreened for eligibility
and screening questionnaires. A consumer that has cleared all prescreening steps will then be
granted access to contact a mental health provider digitally. If there is not a counselor that is
available for the consumer at the moment that individual will be placed into a holding queue for
follow up.

Project Aims
The goal of the Vet Center is to take a more proactive lead with mental health. The Vet
Center differs from the greater VA when it comes to the active duty service member as they are
often restricted to their base resources for care. Having a VA service that is in a position that can
provide care to those who are in the military using technology would reduce logistical barriers. A
Vet Center is a federal entity that would not be restricted to state licensing requirements, and the
ability to meet with a client through a digital screen expands the reach of services across state
lines. The current policy that the Vet Center has with keeping the record separate from the VA
offers protection for the service member accessing care. Having confidentiality reduces potential
risks for service member's careers.
An estimated 12% of military personnel received mental health treatment from
behavioral health resources in the year 2000 prior to the 9/11 conflict (Garvey Wilson, Messer,
& Hoge, 2009). 38% of those who did receive mental health treatment and diagnosis often
departed the service within 1 year (Garvey Wilson et al., 2009). The number of service members
that left the military after a mental health diagnosis is concerning. A measure of success would
be a reduction in the rate of those leaving the service after a mental health diagnosis when
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innovation is operating at scale with implementation into all Vet Center facilities nationwide. It
could be that those who did receive a mental health diagnosis were medically flagged that put
those individuals at risk for separation from service. It is not clear by the data that those who did
leave the military after a mental health diagnosis did leave the service because of the received
diagnosis. There is the potential that the military service may use these medical conditions to
support with downsizing when needed, and this could be the reason why that the system wants to
be very involved in the care of service members in their system.
There is a common theme in the military that there is this generalized fear of the potential
consequences that mental health services could negatively impact a military career (Wilson,
Gettings, Hall, & Pastor, 2015). The military unit is often very close, and leaders are often the
historians of past challenges and experiences of challenges. There could be leaders in a unit prior
to 9/11 who knew people that were processed out in connection with mental health. Just as those
who left the service shortly after a mental health diagnosis maybe there is some truth to the fact
that there are some potential consequences for seeking help systematically in the DoD. This
knowledge from leaders would be likely to share the information with those coming into the
service after 9/11 and to just focus on the mission. The history of lacking trust with the military
is something that can be deep-rooted, so when there are these violations there are generations of
spillover that it will negatively impact with those coming into the military. The fear of seeking
help will impact those who need it the most by creating barriers, and these fears can further result
in loss of hope for the individual who is suffering. This innovation will require a marketing
strategy to increase awareness of the program and ways that the consumer can engage the
agency. Having an online platform that differentiates the Vet Center from the VA will be
required. The unique website for the Vet Center where the innovation will be piloted has features
MILITARY AND VETERAN 14

for the consumer and can be used as a means to make contact to establish services. Having the
appropriate tools to reach, and share information with the military and veteran community will
be a critical component when expanding on the innovation.
Summary of Aims and Implementation
There is evidence that supports the use of mental health interventions through
technological capabilities. It has been found that veterans who live 25 miles, or more away from
the nearest VA facility for mental health care have a likelihood of dropout with mental health
engagement(Koenig et al., 2016). Furthermore, a veteran that lives in a rural area is likely to
connect with a peer over a non-veteran according to an intervention that was used by the VA
using telephone counseling sessions (Koenig et al., 2016). The Vet Center gives priority hiring to
veterans to include the counselors. With service members and veterans that are difficult to reach
logistically, the Vet Center is in a good position with the staff demographics, and the population
served. Some of the next steps for the Vet Center is the shift in policy and practice with
implementing technology into direct client care.
There is this generalized concern that military personnel have reported with the possible
negative impact of consuming mental health services. The military promotes masculinity,
strength, and resilience. Service members often have a concern that seeking support would be a
sign of weakness (Schreiber & McEnany, 2015). The work that is getting done with the
reduction in mental health stigma and community awareness provides a unique opportunity to
scale services by increasing access to mental health services. The aim of this innovation is to
make support services more accessible for the military and veteran community with the use of
technology. It is expected that consumers will have reduced logistical barriers with access to
care, reduced wait times, and the opportunity to meet with a counselor with non-traditional
MILITARY AND VETERAN 15

hours. This pilot will measure the difference in care and evaluate feedback from the consumer.
The current climate with military risk factors is an opportunity to apply pressure on DoD policy
through innovation by external agencies.
Future Action Required
A strong collaborative The current pilot program within the Vet Center system making
use of the VTC technology is an opportunity with various potential. This technology will be used
to engage consumers by walk-in at host Vet Center host site, or deliver care online. The priority
of the innovation to reach as many veterans as, and military personnel as possible. This
innovation with the ability to reduce barriers is expected to reduce the burden of seeking care and
challenging some existing limits. The innovation will collect data to present value on the impact
of the program. The effort with Vet Center leadership on the Video Teleconference program and
the implementation of the innovation. There is a current pilot with the VTC system or online
platform that is in use only by a few counselors across the Nation. The VTC program is the
capability that allows clinicians to interact through a digital screen live in session with their
clients. The use of the VTC program requires special authorization to use the program currently.
A clinician that gains access to the VTC will need specific VA training. There will need to be
updated on policies, and training for clinicians going forward with the existing pilot. It is the
intent that this pilot program will have a strong influence on the use of technological capabilities
going forward that will shape the way care is delivered in the future. This work has the potential
to shape the way that the Vet Center system conducts business in the effort to support the veteran
community with changes in practice. The efficiency and effectiveness of the VTC technology
will require feedback to leadership prior to taking to scale. The collection of data will be
analyzed for the value of the pilot program and how it can benefit the Vet Center system. The
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efficiency and effectiveness of the VTC technology will require feedback to leadership prior to
taking to scale and will give the opportunity for the implementation with the innovation using the
remote staff. The collection of data will be analyzed for the value of the pilot program and how it
can benefit the Vet Center system.
With the adoption of the current pilot project, it affords the opportunity to leverage
technology to serve the military and veteran population. This opportunity is in the infancy phase
of the pilot project. This will allow for more flexibility in the delivery of care as technology will
become the norm with other ways to engage the community. The innovation leveraging existing
technology that is used in the pilot will be called “Direct Link.” This will allow clients to engage
online. Also, it will support the pilot site when it comes to the management of walk-in services.
The innovation with Direct Link will allow service members to access care online without ever
stepping into a Vet Center. The innovation will take the existing pilot with VTC capabilities and
leverage the opportunity with another pilot at a host Vet Center. It is expected that innovation
will have a direct impact on policy and the delivery of care. The innovation takes the existing
pilot and change the approach with how that technology is used. It is expected that this
innovation will increase the quality of care and reduce wait times for the consumer.
Another aspect of the delivery of this innovation is the Vet Center website update. The
host pilot site for Direct Link will require an individual website for the host site. It will be
important to establish a working website that represents the host site. When scaled to different
Vet Center sites will require their own unique site with working features. The individualized
website will allow for access to care. There will be preventative features with secure messaging,
and crisis resources. The website that will host Direct Link with the pilot site will have unique
data collection and tracking features.
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The Vet Center is an extension of the VA with different access criteria that is different in
comparison to the VA Hospital. As the Vet Center evolves in the use of more technological
capabilities it will be important to stay competitive in the delivery of innovative interventions.
The Vet Center needs to clearly define identity what differentiates itself from the larger VA as
the lines are blurred when looking up information about the VA. The update with the website
needs to make it easier for the consumer to find the Vet Center and understand the difference in
services in comparison to the VA Hospital. Every Vet Center location would benefit from an
individualized updated website especially if other facilities are to adopt the innovation from the
Vet Center that will host Direct Link. It will be important to distinguish the different facilities as
they are specific to the access point for treatment.
Innovative Steps Forward
There are currently over 800,000 veterans that are receiving service-connected benefits
for PTSD (Black, Meshberg-Cohen, Perez-Ortiz, Thornhill, & Rosen, 2018). The protocol for
clinicians within the Vet Center system is to assess all vets for PTSD. The Vet Center system
falls under Readjustment Counseling Services (RCS) that gives the mental health counselor the
flexibility to meet the individual where they are without the restriction to the scope of practice.
The use of technology engaging service members before discharge creates documentation of a
possible mental health condition that can be used as a claim to support transitioning out of the
service with resources. This can reduce risk factors for the veteran when receiving benefits post-
military service, and systematic pressures for communities with emergency services.
The VTC system is in the infancy phase within the Vet Center system, and there is value
with this technology. It is unclear to what scale, and how the system will be used. However, it is
an innovative tool to engage the military and veteran community. There have been consultations
MILITARY AND VETERAN 18

with key internal and external stakeholders to leverage the technology in an efficient way that
benefits the consumer. Furthermore, the collaboration with other agencies who might have an
interest in the veteran community could have insight and value to bring to the Vet Center. There
will need to be a continuation of collaboration with internal and external stakeholders.
Large Scale Impact of Innovation
In 2008 the Army exceeded the suicide rate of the civilian population (Wilson, Gettings,
Hall, & Pastor, 2015). There was a housing and financial crisis that occurred in 2008. The
finances and debt that can have serious mental health consequences for people. A general
knowledge exists of the financial crisis and the consequences that occurred in 2008, but there is
little connection with suicide to be found in literature. The DoD practically owns people like
property, and most of the general population may not understand how true that is for those who
are in the military. In the military, there are clearances with different levels and the higher that
clearance is the more intrusive that process can be for a person. Some people in the military
cannot maintain positions in the service without having their clearance as this is an additional
standard or responsibility for the service member to maintain. In some instances, there have been
concerns for clearances when it comes to financial responsibility. There may be nothing to worry
about for the service member, but that all can depend on policies at the time. A large-scale
economic crisis may not only apply pressure on service members and their family’s ability to pay
bills but could also have further psychological consequences regarding the potential for loss of a
military clearance. When there are risk factors for the military community with a lack of
financial resources as a stressor, and then there are concerns that seeking help could also cause
them harm just creates more risks for potential suicide. As of recent, there has been concern
about the Nation’s financial wellness, and as a people, we should be very concerned about
MILITARY AND VETERAN 19

potential risk factors that may be around the corner. We already have a challenging economy and
we could potentially have another crisis soon, and we need to be mindful of that especially for
those that have served in our military. The way to mitigate these risk factors for the military and
veteran population is to have better planning and have more resources for this community even if
it means scaling existing programs. There needs to be more accountability for the military and
veteran population within the VA and DoD. Therefore, this innovation is in response to the
hardships and barriers that are experienced.
With the suicide risk for the military and veteran population, it is critical that more is
done for this community. When the current Vet Center VTC pilot program and the innovation
with Direct Link are taken to scale it will increase productivity for the system. The value of using
technology with direct service in a federal system allows clinicians to provide care in different
states. This will allow for Vet Center facilities that are underperforming have more tools to
provide direct client care. Some aspects of the Vet Center should remain the same especially
with the integrity of not sharing the record with the greater VA as this provides protection for the
individual that is serving in the military. It is expected that an increase in access to care with
reducing barriers would reduce suicide risk for this community. The continuous evaluation of the
program and measures will be used to compare data.
Area 2. Conceptual Framework
Statement of Problem
There is a military DoD instruction that is related to mental health policies. The DoD
instruction 6490.08 indicates when commanders should be notified, and when notification is
appropriate (Department of Defense, 2011). In the service military, mental health providers may
have a dual role of accountability to the system and the service member. This creates a barrier to
MILITARY AND VETERAN 20

accessing care and concern of confidentiality. A lack of trust in leaders, policy, and stigma was
often the motivation for service members to seek out care outside of existing resources (Waitzkin
et al., 2018). The Grand Challenge is to Harness Technology for Social Good within a system
that is external to the Department of Defense (DoD) and VA hospital to reduce barriers
experienced in the service. The proposed innovation is in response to the policies and stigma
that act as barriers for AMSM and Vets that keep them from accessing preventative and
stabilizing care.
There are programs that work with those who have been injured and wounded in the
service. Some of these efforts are designed to support the service member and the caregiver of
the individual. The Defense Health Agency’s Recovery Coordination Program has Recovery
Coordinators who work with those who have been wounded. A Recovery Coordinator is a person
who works with community partners to mobilize resources. Under the Defense Health Agency,
there is an Education and Employment Initiative. The agency works to identify opportunities for
transitioning service members and to find employment matches (Onofre, 2019). Even though
these programs exist for those who have been wounded it is unclear of the effectiveness of this
program at this time. A service member could be provided job opportunities prior to the
transition from the service, it is unclear what service members did to accept gainful employment
based on the advocacy of the program. It is good that this program exists, but will it still be
enough in the long run? Furthermore, there needs to be more access to care for service members,
and resources prior to a serious injury. Waiting for a service member to have a serious handicap
will not promote resiliency. It is difficult to assume that those who have a serious handicap will
have the tools, and necessary coping skills to fully benefit from the program.
Literature and Practice Review of Problem and Innovation
MILITARY AND VETERAN 21

In June of 2018, the Department of Veterans Affairs (VA) VA Mission Act was passed
and signed into law. The VA Mission Act was in response to the scheduling difficulties and
issues with the CHOICE program that was already in place. The commute and wait times for
care are at the heart of the VA Mission Act to address these concerns for the veteran community
that have barriers with receiving the care that is needed (Williams, 2019). The Mission Act will
expand services to include more access to community providers, and to allow the veteran to have
more choices in the care that he or she desires with more options (Office of Public and
Intergovernmental Affairs, 2019). With this current policy, it appears that the focus will be
placed more on the private sector. It is difficult at this time to predict what will happen to
existing VA programs or expanding through innovation with the VA. This program could
potentially be the beginning of the reduction in VA resources. The providers in the community
are not federal entities and would fall under state regulations and would not have the reach that
the Vet Center would for mental health services.
Technology increases access for providers and consumers. Having a cell phone can allow
a person who needs mental health support to reach out for help. The mobile phone applications
for mental health could track changes in behavior. There are various programs that come in the
form of applications that are designed to meet the individual needs of the user. The applications
for smart devices for mental health are expected to grow that already has thousands of programs
available with the Apple iTunes and on Android stores. The importance of technology in the
mental health field can reach those who may have normally not engaged in traditional
interventions, or who have logistical barriers (National Institute of Mental Health, 2017). The
use of technology and engagement in mental health services with this method could be more
MILITARY AND VETERAN 22

popular with the military and veteran population because of the stigma with access to mental
health services.
The use of innovation has shifted in the traditional sense with companies that used to
work toward beating each other in their perspective markets. Those agencies that have been more
successful in their space with innovation have done market research to understand the needs of
their target population. Organizations that have done well at creating value are very strategic
look at what similar agencies are doing but place more emphasis on gaps in the within the
landscape (Kim & Mauborgne, 2004). This approach can be applied in different settings with
different goals. There is an overlap when it comes to creating value for others, and this can be
done by assessing for needs. It is about finding a need and filling it that can result in the audience
becoming drawn because it is a good fit for that consumer. Having a unique understanding of
trends and doing research will be helpful when attempting to deliver. Understanding the needs of
the military population, and what is missing for this group is key to mobilizing resources.
Landscape and Environment
Two dependents of a person who served in the military have encountered barriers with
their own desire to serve in the military. There is something called the dependent medical record
that was retrieved when attempting to join the service. The dependents under the service member
used mental health resources under their father. When these two daughters of a military service
member were of age to join the service, they were both denied access to join based on mental
health services that were received many years prior to attempting to join the military. The family
was not aware that the military would move to merge the dependent medical record and
electronic health record while trying to serve in the military. The two teenage daughters of an
Army Major were denied the opportunity to serve in the military, and this is where the civilian
MILITARY AND VETERAN 23

records differ from the military system. These two children of the service member were denied
waivers for mental health to serve because of treatment received in the past with recent mental
health evidence that supports that there is nothing serious that would prevent them from serving
with evidence from civilian and DoD behavioral health providers. The process began in 2004
with the merging of records in 2004 (Jowers, 2018). The merging of records will create barriers
for other dependents from entering the service as well just as this family. Some of these
dependent children are becoming the age to serve in the military who were encouraged to get
help if needed are now encountering a problem with entering the military. People in the service
are not informed that medical, or mental health information within the military system continues
to be used if that child ever wanted to serve in the military (Jowers, 2018). The more that mental
health services impact military service in some way it continues to be a barrier with help-
seeking. The fact that military service members and families get mislead about mental health is
likely to increase the lack of trust with the system. There are long term consequences with the
policy of the military as it can influence governmental agencies like the VA post-military
experience that might deter from consumer engagement.
More than half of all veterans in the Nation receive care and resources outside of the
Department of Veterans Affairs (VA) (News Staff, 2019). It has been found that providers in the
civilian sector often lacked adequate knowledge about the military and veteran community.
There is a need for providers and other health settings to become more familiar with the veteran
community to include ways to identify those who have served in the military. Just because a
person may have served in the military it does not mean that the VA will be the best fit for them
or a logistically sound engagement. On the other hand, there are some groups of vets who
consume VA resources and civilian community health care resources (News Staff, 2019). There
MILITARY AND VETERAN 24

are many layers that are associated with participation with the VA. With going beyond the
logistical hurdles that some vets experience there are also VA eligibility criteria for health care
that is sometimes connected to VA service-connected disability ratings. There continues to be
difficult for the military and veteran population with navigating resources for them.
Social Significance
The military has gone through many changes over the years from a draft to a volunteer
force. The design of medical resources has changed in time for the military and veteran
communities as well. It is proposed at this time that the military reduces 20% of the medical
positions that equate to 18,000 positions approximately by the DoDs budget for FY 2020
(Cowan, 2019). A reduction in medical resources not only can impact the service member, but
their families are most likely to feel that impact with the proposal to downsize (Cowan, 2019).
The reduction in medical resources may have serious consequences for those who serve in the
military. A service member is likely to be already guarded with their system, and there is often a
lack of trust. With the reduction in resources, it may expand the existing barriers with support
and access to care. This shift in priority could influence service members to not get help as it
would just be too difficult to receive the care needed. A reduced medical force would mean the
reduced likelihood that a service member will receive medical documentation for ailments that is
a critical piece with accessing resources post-military service in the civilian sector with VA
resources.
A male is four times more likely to commit suicide than a female. It is estimated that 30
percent of those returning from the combat zone is likely to experience a mental health condition
(Abrams, 2018). The public view and perception of mental health can spill over into military
service that can create a barrier with mental health services. It is estimated that one in four
MILITARY AND VETERAN 25

people struggle with a mental health condition worldwide (Abrams, 2018). Throughout Europe
and the U.S. population, there are approximately 75 percent of those who have a mental health
condition that does not receive treatment for their symptoms (Abrams, 2018). The stigma
remains one of the main factors for not seeking treatment that is ranked four out of 10 different
variables for not engaging with mental health care (Abrams, 2018). The perceptions of mental
health continue to be a problem and the culture of the military just fuels the problem. Even
though women are a portion of the military who are worth discussing risk factors with that
group. However, most of the service is dominated by males who have a larger risk factor than
females for suicide. It would be worth targeting males in the military when it comes to mental
health given the increased risk. There is the potential for further research for women in the
service who and what may reduce the risk factors for suicide in comparison to males with gender
differences.
Mental health is the number one main issue worldwide that is the main cause of
disability. The mental health issue for the military across all branches is the leading cause of
hospitalizations for those who are in the service (Garvey Wilson et al., 2009). The prevalence of
the impact of mental health and the impact it has on real people throughout the world is an
important notion to note when addressing the significance in the effort to reduce the stigma of
mental health. When addressing and working with the military population it is important to
indicate that mental health is the leading cause for hospitalizations and that this issue is
something that impacts everyone to normalize the experience and encourage help-seeking
behavior.
It is estimated that there are approximately 1 million spouses that makeup support
systems for the military component (Lewy, Oliver, & McFarland, 2014). There is the likelihood
MILITARY AND VETERAN 26

that if military spouses engage in mental health services that there is a better chance that services
will be delivered from the civilian population in local communities. It is concerning that mental
health professionals in the community may not understand the limits that military spouses
encounter or understand military culture. The collective information on the challenges that
military spouses face was recruited to be participants primarily through various social media
platforms. The accessing of systems continues to be problematic for spouses with the spillover
from the service member's resources that do not always protect a person’s career as medical
ailments can put a person at risk of separation from the service (Lewy et al., 2014). The military
population that is serving already encounters enough barriers to mental health resources to
include policies that can jeopardize a career. The mental health concerns are even a larger
concern when considering the service member and risk factors for the families. This just speaks
to the need that there is more that is needed for the military population.
There have been well documented mental health issues and concerns for those who serve
in the military. Those who are often overlooked are the families of these service members and
veterans. The role changes, deployments, and changes of duty stations place pressure on the
family unit. These stressors that are placed on a military spouse have psychological
consequences that place the individual at risk for depressive symptoms. A military spouse was
more likely to be at risk for depression when a service member has psychological difficulties
(Donoho et al., 2018). The innovation seeks to be able to engage those who are still serving to
address those that still serve in the military. If the service member is functioning better, then that
will have a spillover on the family unit that is part of the service member. However, it is
difficult to determine when the innovation is a pilot. The long-term goal, and when innovation is
MILITARY AND VETERAN 27

taken to scale it will have the potential to have a much broader impact with the use of
technology.
Conceptual Framework

CONCEPTUAL FRAMEWORK for [Direct Link]
by (Adam Castro, MSW, DSW Candidate)

PROBLEM STATEMENT
policies and stigma that act as barriers for AMSM and Vets that keep them
from accessing preventative and stabilizing care.

Challenges for target population
Challenges for system
- Mental Health and other
Health related ailments
- Operational Tempo
- Work/ life balance
- Hazardous working environment
- Military Culture
- Service members have barriers
with accessing mental health
services over concern with
negative impact to military
career.

.

- Lack of policies that support
safe environments for healthy
development of all individuals.
-System is reactive to
individual problems over
proactive.
- Lack of policies supporting
leave of absence /aassessment
of readiness to return to full
duty in military.
-There is a lack of
understanding between VA,
DoD, and RCS.

Personal Outcomes

- Non-Judicial Punishment or Court
Marshall.
- Unhealthy Coping Skills
- Feeling of being trapped
- Performance Issues
- Stigma of mental health
- Resilience and self-reliance over
help-seeking

System Barriers
- Help seeking barriers
- Military Culture
- Punitive System
- DoD Medical Policies
- Deployable Vs. Non-
Deployable
- Career
- VA eligibility criteria
- Access to care issues
with military Discharge.

GOALS Programs
Policy/Legislation

- The ability to register and
enroll in services online.
- Have the consumer
receive a quality
intervention and
appropriate referral for
treatment.
- Allow for the ease of
access with timely
interventions.
- VTC stationary system
for use with walk-ins.
-

- Increase in successful
transitions.
- Awareness of
community resources
outside.
- Reduce wait times.
- Increase access to care
for veterans and service
members.
- Reduce Logistical
Barriers

- Reduction in Force
- Adjustment to
medical qualifiers
- Better care with
Discharges
- Advocacy
- Confidentiality with
separate system
Challenges for community

- Lacks the resources to address
PTSD and other mental health
conditions experienced by service
personnel
- Limited ability to address
Domestic Violence & - suicide/
Homicide Risk
- Leadership
- Harassment
- Work place stressors
- Difficulty with transitioning

Community Outcomes
- Family Stress
- Children vulnerable to
trauma
- Spillover from stress of
service member on to
families

MILITARY AND VETERAN 28

The military service members continue to be at risk with continuous deployments, and a
system that does not support help-seeking behavior with current DoD policies. The barriers that
are associated with the policies that service members encounter often have real consequences. It
is too often that a service member will get into trouble, and in some cases, it is too late to have a
positive intervention. When it is too late for an intervention, and a person receives an
unfavorable discharge this leaves the individual to stumble through civilian life. This innovation
is focused on increasing access to services while reducing logistical barriers at the same time
protecting confidentiality.

MILITARY AND VETERAN 29

Project Model

The Project model highlights the benefits for the intended target audience, and this is the
use of technology with VTC. The evaluation component will capture the data with the use of

Vet Center with
military and
veteran population

Vet Center
Modernization and
development to
decrease barriers

Developmental targets to Deliver Care

❑ Increase in the quality of services
with innovation.
❑ Early Intervention and preventative
care with appropriate referral.
❑ Provide confidential protection with
services for service members.
❑ Increasing access to care by
leveraging technology.

❑ x
❑
❑ X
❑ x
Benefits

❑ Networking-develop collaborative outreach projects to develop collaboratives
with non-profit organizations, DoD, DVA, and other federal entities to support
the military population.
❑ Develop community partnerships for referral process, and access to services that
can meet individualized needs.
❑ Increase access to care for military service members to support successful
veteran outcomes.
❑ Develop resources on website for providers to leverage in working with the
military population.
❑ Have web-based tools available to support professionals on website, and the
consumer.
❑ Make available common forms that that veterans and service members often
need.
❑ The use of technology within a federal system will increase access for the
military and veteran community.
❑ Build a pilot program that can be duplicated with meaningful impact for the
future.

Methodology
Web-site and Military Community

❑ Develop web-site as starting point
for entering the system.
❑ Develop (MOU) to include
amendments with access to RCS
System.
❑ Leverage web-site as entry point
for clients to reduce access to
care and logistical barriers with
care.
❑ Increase effectiveness of the VTC
program by allowing for provider
and consumer feedback.
❑ Increase knowledge of service and
advocacy of system consumption
through partnerships.
❑ Have a larger scale presence with
the VA and DoD.
❑ Have readily available resources
for providers to share with
consumers on the VTC platform.
❑ Continue to develop web-site to
increase functionality to promote
ease of use for consumer and
provider.
❑ Have a pre-survey and post-survey
available for Vet Center consumers.

❑ Make website and services more well
known for consumer engagement.

Web-based Therapy System
Communication

❑ Utilize the community networks to
identify community leaders from
military and veteran population
to provide feedback.
❑ Develop a feedback loop with Vet
Center leadership.
❑ The analyzing of data from the military
and veteran population will help with
identifying the needs of the
community,
❑ Collaborative efforts with the greater
VA, and DoD.
❑ Consult with innovators, and
influencers to bring awareness.

❑ Year 1: Increase effectiveness of VTC program. Update
policy and implementation process of VTC. Have the
program become a normative process and common
practice in the Vet Center system. Increase training
programs to prepare clinicians to use the VTC program
in real time.
❑ Build and add functions of website capability for Ex:
Video Teleconference, Pre and Post test of surveys,
materials available to providers on website. Increase
feedback by providers and consumers to achieve quality
improvements with the system.
❑ Year 2: Add staffing to the organization by having
licenced clinicians. The additional staffing will be
remote providers to provide services to vets that come
through the website portal or walk into a Vet Center.
❑ Allow for access to the RCS system for community
partners for continuity of information sharing and
documentation through a MOU.
❑ Increase record access and sharing with other Vet
Centers.

Product/Program Development
Evaluation Component

❑
❑ Use qualitative methodologies to better
understand the challenges that service
members, veterans, and their families
experience. The understanding of the military
and veteran community will support the
development of the innovation.

❑ Use of quantitative methodologies to examine
the risk factors, barriers to care, and access to
care problems.
❑ Increase awareness of leadership regarding
needs of the veteran community.
❑ Monitor the use of Vet Center VTC program
❑ Take feedback from consumer on VTC
program.
❑ Reduction in need of vet to engage on site.

❑

MILITARY AND VETERAN 30

measures. The program development will have phases for the implementation. The Web-based
therapy system is the VTC program that will require Vet Center site-specific web development.
The long-term goal is to collect data and show proof of concept to advocate for more resources.

MILITARY AND VETERAN 31

Logic Model

Target Population
• Intention is to reduce barriers with
access to mental health services.
• Policy and Stigma act as barriers to care
with military service members.
• Active Duty Service Members/
Veterans.
• Assumptions that service members
have all resources needed.
Inputs
• Website
• Video Teleconference capabilities (VTC)
• Additional Staff to work remotely to
manage walk-in services and those who
enroll in services through website.
• Marketing locally, online, and social
media.
• Collaborative partnerships to support
with dissemination of information
regarding innovation.
Activities
• Measure risks for the military
community to bring value.
• Intervention can make use of pre and
post test
• Collect data on intervention and ease of
use.
• Measure quality of care and length
between appointemnts.
• Gather feedback from consumer and
provider.
Outputs
• Website web-based Therapy for
initial screening and assessment.
• System that measures incomming
consumers with pre and post test.
• Keep a tracker on the website with
number of sessions provided.
• Resources for providers and
clients on the website.
• # of sessions provided with VTC
Intervention.
• Vet Center statndards with output
of 50% or greater dircet client
time.
Short Term Outcomes
• Potential for military leadership to
see more of the need for early
intervention to promote long term
positive outcomes.
• Ability to provide a safe space,
ease of access, and confidentiality.
• Knowledgeable about military
related resources in case a referral
is needed.
• Increase resources and access to
promote higher level functioning .
• Increase community presents and
innovative lead by the Vet Center.
Intermediate Outcomes
• Veterans more likely to know their
resources.
• Military Spouses supporting more
services.
• Service Members more likely to
engage mental health services.
• The pupose of the intervention is
to reduce risk factors.
• Promote Help Seeking Behaviors.
Long Term Outcomes
• Possible increased pressure for the
military to change policy.
• Long term plan to scale VTC technology
within the Vet Center system.
• Veterans engaging more in VA
Healthcare.
• Potential for military and veteran to
increase care quality by external
pressure through Vet Center innovation.
• Ability to gather attention and support
of technology with Vet Center system.
Anticipated Impacts
• The suicide rate will drop for service
members and veterans.
• Better understanding of the the
landscape ahead with transitioning into
the civilina sector.
• Increased helpseeking behavior.
• Possible change in military culture and
policies.
MILITARY AND VETERAN 32

The theory of a program can be found in the logic model. The logic model can lead to the
formulation of solutions to questions about intervention. The activity that is done within the logic
model helps describe the intent and the potential outcomes of success. The logic model should
flow and have the potential to lead with results (Wilder Research, 2009). The use of the logic
model begins with the target population and finishes with the intended impact.

VET
CENTER
MILITARY AND VETERAN 33

The flow chart describes the innovation and how care is accessed. A veteran can walk-in
to the Vet Center or make contact online. Either way that contact is made with the Fresno Vet
Center the individual will be seen by a licensed psychologist digitally. The individual will be
assessed and provided with the appropriate intervention with referral. The remote psychologists
will be provided with Vet Center access and the VA hospital electronic records that can assist
with coordinated care.
Area 3. Problems of Practice and Innovative Solutions
Proposed Innovation and Its Effect on the Grand Challenge
Veterans will be able to access VA resources through going to their local Walmart soon
with recent collaborative partnerships. The telehealth technology will also be used at specific
American Legion and Veterans of Foreign Wars locations that will target rural and underserved
areas first in the roll-out of the initiative. It is anticipated that T-Mobile users will be able to use
an application offered free for veteran clients that wish to use similar services through their
phone carrier. In 2018, an estimated 725,000 veterans used some sort of remote care with about
45% of them who used those resources lived in rural areas that encountered barriers to treatment
(Shane III, 2018). The community access points with the telehealth technology are expected to
connect the veteran with various resources within the VA system. The partnership with VA and

Phase 1:
Identify Gaps in current
services
Identify barriers
Identify needs of services
Understand the landscape

Phase 2:
Design Program
Current pilot
Select pilot site
unsolicited prop
Recruitment
Training
Website Design

Phase 3:

Implement
Gather Data

Phase 4:

Assess progress/success
Evaluate
Revise based on
evaluation
Explore additional sites

MILITARY AND VETERAN 34

Walmart is strategically based on how Walmart locations are positioned in different cities. There
is a Walmart usually within 10 miles of distance for 90% of Americans, but that much different
in comparison to the distance that most veterans that need to travel to the nearest VA facility
(Shane III, 2018). This effort with technology highlights the important role that technology will
have with enhancing the client experience. The innovation using VTC within the Vet Center
system is at a unique time when there are more considerations and options available for the
consumer.
Views of Key Stakeholders
The Defense Health Agency (DHA) is responsible for the Department of Defense (DoD)
for the readiness of approximately 9.4 million personnel so that missions can be carried out for
military operations. The DHA is charged with seeking out innovative and cost-effective ways to
deliver health care interventions to military service members. This agency uses military facilities,
community networks, and TRICARE to deliver care to service members. Through the expansion
of community partnerships, the agency can deliver care for some of those service members for
accessing care (The Defense Health Agency, 2017). The agency is providing care to service
members is more for the system at large than the individual. Even though care is provided to
those in the military the system is a very intrusive employer that is more accountable to military
readiness than the individual. The lack of privacy and confidentiality are often barriers to
accessing care in the military. The emphasis of readiness for the mission treats people like
numbers and is different from health care systems in the civilian sector. The policies that are in
place for medical readiness can threaten a military career.
The DoD has been a strong force in the spillover of culture in other organizations. The
military works closely with other private and federal entities that sometimes have similar
MILITARY AND VETERAN 35

interests and values. The sense of duty is apparent in the military culture but may not be
represented the same in other institutions. The service promotes self-sacrifice and focusing on
the mission of the military making large organizational goals the priority. There is the apparent
promotion of strength and aggression in the service that is designed to benefit the organization.
The cultural norms of the military have very little concern for the individual service member, and
there are often clearer differences in the private sector. The individual rights of a person serving
in the military differentiate from the masses of civilian counterparts. The use of teamwork and
perfection when it comes to performance in the military is expected, or there could be severe
consequences (Tinoco & Arnaud, 2013). When it comes to employing those who are veterans
and working those who have served post-military it is imperative to understand the values and
norms that come with that experience to work with the individual’s strengths that can bring value
with a mutually beneficial alliance in the workplace. Vets that access healthcare are often
attempting to give systems a chance who have already may have buried their symptoms for years
as a sense of duty to the military mission, and this is extremely important for agencies that may
have encounters with the veteran community as consumers.
Evidence and Current Context for Proposed Innovation
If a service memberʻs mental health status is severe a commander could place limits on
an individual or recommend separation from the military based on presenting factors. A service
member that presents as a threat to self, others, or the mission then the next step is likely to
involve the chain of command (NAMI, 2019). The power that a commander has is very far-
reaching. The authority that commanders have to make direct recommendations based on mental
health, can be of some concern, and especially if there is a lack of trust with the individual’s
chain of command. A person that is a threat to the mission is very broad, so it depends on how a
MILITARY AND VETERAN 36

person interprets the situation. If a service member were to admit that he or she has a problem
this may bring unwanted attention by leaders. Service members who have a strained relationship
with leaders may be less likely to be vulnerable about mental health issues, and the handling of
that sensitive information.
The military service member often finds themselves pitted in the middle with a dual role
as patient and having primary roles to the mission of the military. There is a lack of trust in
accessing mental health resources in the military. The lack of confidentiality for medical issues
in the service act as a barrier to care (Clark, 2018). The military mental health providers are
placed in a challenging position that often looks different in comparison to the civilian sector
with accountability for the client and the military system. Over 90% of service members report
that there was a lack of quality of care for mental health and nearly 40% indicates a lack of trust
in accessing care (Clark, 2018). A college professor Dr. Howard Waitzkin expressed concern for
the mental well-being of service members and the ethical concerns associated with the design of
military medical policy. The University of New Mexico Professor Dr. Waitzkin mentioned that
the military should be encouraging the use of private-sector mental health that can offer more
protection with confidentiality by not sharing the client information (Clark, 2018). It is difficult
for a service member to have a quality mental health services that are confidential. The Vet
Center under the VA could be of service by filling in the gaps with confidentiality. Furthermore,
the proposed innovation would be to use VTC technology with a Federal entity that can reduce
some of the logistical difficulties while protecting confidentiality.
The lack of awareness of mental health services may have serious consequences on those
who are suffering that can result in missed opportunities to receive the needed support. Even
though there has been an increase in consumption of mental health services worldwide
MILITARY AND VETERAN 37

awareness of mental health rates lower in importance with comparison to physical health, or
diseases. In some instances, people may avoid mental health services because of cost, lack of
understanding by social support, and the generalized stigma that comes with a mental health
diagnosis. The lack of acceptance for those with mental health conditions will often increase
isolation behaviors that increase risk factors for the individual. The use of marketing and
awareness campaigns for mental health may increase inclusion and acceptance especially if
framed in a medical model that highlights the condition more so than the person who is suffering
(Mannarini & Rossi, 2019). The military has tried to reduce the stigma associated with mental
health, but there is still the stigma associated with help-seeking. The military culture promotes
strength and masculinity that does not support an individual with vulnerability. cite
There has been a growing discussion about gun violence and mental health than in the
past. It is estimated that half of those in the United States would meet the criteria for a mental
health diagnosis. This is the reason that the discussion around mental health continues to grow.
A major topic that is concerning mental health are the existing barriers with access to care. Even
though mental illness has been discussed often in the media, but there is only about 4% of
incidents that are associated with mental health issues (McGinty, Kennedy-Hendricks, Choksy,
& Barry, 2016). The fact that media has connected mental health with violence puts the military
and veteran community to be placed at a higher level of risk. The military population has been
trained to react and respond to potential threats that increases the probability to make very fast
decisions. It is important to maintain empathy for the mental health conditions so that the public
does not shame those for seeking help or have a fear of those who are suffering.
Less than half of the 22 million veterans in the U.S. are using their VA resources, but a
contributing factor can be different eligibility benefits associated with receiving health care that
MILITARY AND VETERAN 38

contribute to the existing barriers with access for consumers (Tanilelian, Batka, & Meredith,
2017). The use of private mental health care has been more popular when it comes to receiving
mental health treatment for service members, veterans, and their families. There is an estimate of
over 40,000 non-profit organizations that work with the military population as a response to the
current conflict (Tanilelian et al., 2017). The different systems, partnerships, and relationships
have been used to address some of the existing barriers of service (Tanilelian et al., 2017).
Comparative Assessment of Other Opportunities for Innovation
The strategic plan for the VA is to have a greater choice for veterans, improve
timeliness of service, suicide prevention, focus resources more efficiently and modernize
systems (Department of Veterans Affairs-FY 2018 Agency Financial Report, 2018). This
innovation will provide more choices for the military and veteran community. It will increase the
timeliness of services and will have a direct impact on the quality of care received that is
expected to reduce risk factors. This innovation using technology with VTC will leverage
resources by reducing overhead costs at facilities by providing care remotely for those that make
first contact with the Vet Center. The strategic goals for the Vet Center with the innovation align
with the VA initiative.
The more mobile devices that are used create the opportunity to bring value to the
consumer for the delivery of health care resources. The use of technology in the health care
landscape is a way to empower consumers and expand access to individualized health
management. IBM partnered with the Department of Veterans Affairs to create a program called
Get Results in Transition (GRIT) as an example of technology in health care (IBM, 2019). The
GRIT program is one of the first programs to take the data of information on the user that
provides tools to the individual. This program was designed for the military and veteran
MILITARY AND VETERAN 39

population, so the consumption by an active duty member is appropriate. This mobile program
will use technology to identify the strengths and challenges of the user to support with managing
through stressful life transitions (IBM, 2019). Understanding the landscape of consumer
capability and needs is critical with any innovation.
Just under half of the adults in the U.S. population have a tablet, or computer that is
used. Over half of the adult U.S. population has used a smartphone estimated at around 68% for
users (UIC, 2018). In 2020 the Cisco agency anticipates around 11 Billion connected devices.
The smartphones are anticipated to become about 50% of the global technological market in the
year 2020 (UIC, 2018). The health care applications on smart devices are expected to grow 20%
per year (UIC, 2018). The use of technology in health care can deliver access in a way that is
personalized, cost-effective, and easy to use. Experts in the field expect this technology to grow
and develop that can allow providers to interact with consumers that have already reduced the
number of emergency room visits (UIC, 2018). The success with technology has been very fast
and it has come a long way to simplify programs that have been made simpler to increase
consumer use.
With the advancement of technology, it expanded resources to the consumer. Some of
these advancements include better picture quality and sound to provide a quality engagement
between a provider with the consumer. The era of the smartphone replaced old working cell
phones and pagers that were used in the past. The first phone that had communication and
computing features was the Blackberry that was launched in 2002 (Ventola, 2014). The rise of
smartphones really made their mark around 2007 to 2008 with iPhone and Android devices
(Ventola, 2014). It was not until 2010 that the iPad was introduced, and other companies
followed suit with the trend of tablets bringing value to people through portability (Ventola,
MILITARY AND VETERAN 40

2014). It was not until 2011 that the iTunes Appstore started to focus on providers in the
healthcare field that was modified a couple of years later to include resources for the provider
and access for the consumer (Ventola, 2014). The gap between 2002 and 2007 was a big
difference in the functioning capabilities of phones (Ventola, 2014). Just over 10 years later these
products and consumers have broader access (Ventola, 2014). These technological resources can
do more in the health care field to include mental health services.
Comparative Analysis

It is important to do an assessment of the market prior to introducing an innovation that
has the potential to diffuse a targeted problem. The number of medical applications that are
available to the consumer shows that there is a need and demand for the consumer to be in the
driver seat with their care. The target population will need the technology to receive innovation.
The veteran population is more likely to be older than those who are still in the service, so the
active-duty component is more likely to savvy enough to engage with the VTC innovation. The

Identify
Program
Name
Medical Applications for
smart Devices.
Number of Smart Phone
users.
VA Partnership with Walmart and Veteran
Organizations.
Talkspace
(Citation
for Source
of
Informatio
n)
Wang, B., Park, J.-Y.,
Chung, K., & Choi, I.
(2014). Influential Factors
of Smart Health Users
according to Usage
Experience and Intention to
Use. Wireless Personal
Communications, 79(4),
2671–2683.
https://doi.org/10.1007/s112
77-014-1769-0
Wang, B., Park, J.-Y.,
Chung, K., & Choi, I.
(2014). Influential Factors
of Smart Health Users
according to Usage
Experience and Intention to
Use. Wireless Personal
Communications, 79(4),
2671–2683.
https://doi.org/10.1007/s112
77-014-1769-0
https://www.militarytimes.com/news/2018/12/07/o
nline-va-medical-appointments-expanding-to-
walmart-sites-vfw-posts/
https://www.talkspace.com/?utm_expid=GAX1.2.Gxk2DWaSSRuU9BgJwx8RE
A.18285.2
Program
Snapshot

17,000 medical related
applications.
Number of smart phone
users
Increase access and provide live care through a
screen
This is an online program that allow for the consumer to enroll online and meet
with a therapist.
-
Descriptio
n
Medical There are over 91 million
smart phone users in the
United States and over 1
billion users worldwide as
of 2011.
The potential to reach veterans that have logistical
challenges with accessing the VA.
Every therapist is restricted to serve clients in states that their license is held.
-History This is part of technology
and the evolution with
devices that have increased
access through technology.
The phone has evolved over
time and has become a
mobile computer with the
technology advancement.
This is something new for the VA. This program is relatively new.
-Purpose Assessment of devices and
need for consumer use.
The ability to communicate. This is to reduce issues with access to care. This way of interacting with a therapist reduces logistical barriers.
-Program
Structure
The data and programs are
broad.
Assessment of users. The use of technology and using community
partners.
The cost is somewhere between $65 and up with different packages that have
different benefits. All of the different packages can vary on text, voice, and live
video to include the amount of use the consumer gets with the cost.
Summary
Table

MILITARY AND VETERAN 41

greater VA has used similar interventions like VTC, but the VA is likely to miss out on the
active-duty component as most bases have their own resources that are intrusive because of
mission readiness. The website Talkspace is a program for the general population that has a cost
associated with services and can bill employers that have benefits for their staff. The issue with
Talkspace is that there are charges and that they are restricted to state licensure requirements.
The Vet Centre would not be restricted to state practice as a federal entity that has no cost for the
beneficiary, and the use of VTC will allow to expand reach to clients.
AREA 4. PROJECT STRUCTURE, METHODOLOGY, AND ACTION COMPONENTS
Description of Capstone Deliverable/ Artifact
The prototype will be the use and implementation of VTC capabilities within the Vet
Center system. The VTC capability will be technological use in the area of mental health under
the Vet Center system. This will involve the modification with interventions delivered, and to
streamline the capabilities to the point that it becomes common practice within the agency. The
use of an unsolicited proposal will be used to describe the intervention. The unsolicited proposal
will serve as the foundation and the impact of implementation into practice. This proposer has
witnessed the use of the VTC program with clinician to clinician demonstration.
There will need to be a Memorandum of Understanding (MOU) to allow for the licensed
psychologist to have the same access to the VA hospital chart and RCS Net Vet Center chart
remotely. This access is granted will have further implications in the streamlining of client
information and the sharing of records. The purpose of increasing access for the provider is to
allow for better assessment, continuity of records, and the sharing of information. This proposal
has the potential to expand access for community partners and contractors within the community.
MILITARY AND VETERAN 42

A client will have the potential to access the VTC system in person, or online. The Vet
Center has a policy to collect the vet’s information that is seeking access to the system. This can
be an active duty military ID, DD214 discharge forms that indicate a deployment to the combat
zone. The MST community will just disclose at entry into the system for this group to receive
Vet Center services.
This proposer recommends that a pilot program be launched within the Vet Center
system. This will act as a model to provide care with the use of technology as an intervention and
implementation into the policy and practice. The greater VA has run comparisons to previous
years when it comes to the responsiveness to client needs by doing an assessment of performance
(Department of Veterans Affairs-FY 2018 Agency Financial Report, 2018). The innovation with
the use of access to the Vet Center system will be used for initial access within the Vet Center
system. The provider will be remote that will save on cost with onsite resources. The remote
licensed psychologist will have access to Vet Center records to document in the chart and allow
for continuity of the chart record.
A veteran who has a PTSD diagnosis is likely to engage in high-risk behavior and
unhealthy coping strategies. It is likely that a veteran that is suffering from a mental health
condition could also receive other services within a primary care health setting. The use of
mental health in primary care was a way to address the gaps in services (Possemato, Wray,
Johnson, Webster, & Beehler, 2018). Just as a veteran who needs a mental health intervention in
the primary care setting the Vet Center will strive to do something with the use of the VTC
system. The VTC system will allow vets to access care online, or in-person to meet live with a
licensed psychologist through a digital screen. All Vet Center staff have access to the VA
hospital record, and this allows for collaboration with multi-disciplinary teams. The protocol for
MILITARY AND VETERAN 43

the Vet Center is to assess for PTSD first for assessment with serving the combat and MST
population.
There will be a survey that the client will do prior to engagement with a clinician and this
will speak to the potential need for services that can also give insight for appropriate referral and
follow up intervention. The intended measures of the innovation will be quality of care,
satisfaction, cost-effectiveness, ease of use with access to care for the consumer to include
provider satisfaction (Shore et al., 2014). This innovation will collect information and data on
client care through both online and Vet Center Artificial Intelligence (AI). The implications with
the use of technology can change policy and practice for all clinicians within the Vet Center
system.
The Vet Center uses AI for data collection and measures. It will track the provider's
output, and the standard that every clinician has is at least 50% direct client time in an 8-hour
workday. It is not just the provider that is tracked, but the consumer as well. It will allow for the
documentation in the chart, and track visits. There is also a section in RCS Net for assessment,
documentation, intake, military history, and treatment plans.
Every Vet Center across the nation has a room dedicated to a VTC system. This system
has been used primarily for conferences with other Vet Center locations and conferences with
other providers that share similar capabilities. With the technology that is already available, it
will be used to engage the consumer who walks in at the Fresno Vet Center. The intended
purpose of this innovation is to provide timely intervention, assessment, and appropriate referral
for services. The goal of using this innovation is to reduce the wait times and to provide quality
engagement with the consumer.
MILITARY AND VETERAN 44

A mental health professional in the military is required to follow the directive of the DoD
with the disclosure of a service member's mental health condition. There are specific reasons that
are listed in the directive for disclosure of patient information. The potential for harm to the
mission, or conditions that interfere with duty requires that the individual’s chain of command be
notified (NUMBER 6490.08, 2011). Some of the reporting requirements that are directed by the
DoD can be subjective. The fact that mental health can be subjective can create an additional
barrier to accessing care. It is possible that if a service member has a lack of trust for the system
or leadership that the subjectivity of a provider can reinforce some of the same concerns within
that service member. The Vet Center system can offer more and reduce risk for engaging a
separate system.
This innovation utilizes existing telehealth capacity (Video Teleconference (VTC)
capabilities) and restructuring this capacity to increase access and utilization through the Vet
Center under the Department of Veterans Affairs (VA). The value that the Vet Center can bring
to the military population is through the existing system of keeping the record confidential from
the VA and the Department of Defense (DoD) to reduce risk factors for those who are still
serving in the military. The DoD guidance 6490.08 lists nine reasons for mental health treatment
to be reported to the chain of command. These reasons are harm to self, harm to others, harm to
mission, special identified person, inpatient care, acute medical conditions that interfere with
duty, substance abuse, command-directed assessment, and other circumstances determined on a
case-by-case basis (Department of Defense, 2011). While many of these reasons seem like
common sense, there is ambiguity around what might constitute “harm to the mission,” and these
terms are subjective and can be used to describe someone who is experiencing high stress,
temporary anxiety or depression. This innovation reduces the risk of the service member getting
MILITARY AND VETERAN 45

medically flagged and putting the career at risk. If a service member is receiving counseling at
the Vet Center, and there is no need to have any other sort of intervention then the information
will not go any further.
The Vet Center does not share the record with the DoD and the greater VA health care
system because of confidentiality reasons. The VA health care system reports to the DoD when
needed. The sharing might be a rare occasion with VA to the DoD with a person serving in
active duty because they usually have their own resources. The part-time military, such as the
guard, or reserves may not have the same access to resources that the active-duty bases have for
their personnel. It would be more common to have a person in the part-time military access to the
VA healthcare system.
The VA has been making use of technology with innovative ways to connect with their
consumer. There is an online self-help portal that can be accessed on a smartphone, or computer
to manage symptoms. The use of applications for mental health, wellness to include similar
programs outside of the VA are available for consumption (Hartzell, 2019). These resources can
support the military and veteran population. The programs are designed to support wellness and
increase functioning. The use of technology with supportive programs can be a cost-effective
way to receive care without seeking professional intervention.
The VA health care system partnered with the DoD in the delivery with culturally
competent material with their applications. The telemental health program can be accessed by the
veteran consumer at request. Those that are not enrolled in VA healthcare could be eligible for
Vet Center services (U.S. Department of Veterans Affairs, 2019). Even though the VA
healthcare system offers telehealth services to the consumer it is difficult to identify at what
scale. The VA has health care that has eligibility groups that have different levels of access and
MILITARY AND VETERAN 46

benefits for health care. The VA disability service connection can help and support with health
care benefits as this changes the eligibility criteria for the veteran in the VA health care system.
The Vet Center does not have the same eligibility criteria that the VA health care system uses.
The Vet Center can be used as a first stop when there are eligibility issues with access problems
with VA health care. The Vet Center can document the mental health history of a veteran
regardless of the war era to be used for a service-connected claim, and if approved can increase
health care benefits within the VA health care system. The Vet Center criteria for services are
combat and MST, but those who served in peacetime would need to be seen outside of the Vet
Center.
Even with the VA using the telehealth system to engage with veterans, it is utilized for
treatment. There are barriers to engaging the VA healthcare system for some veterans because of
the eligibility criteria, and provider knowledge. A veteran would often need a referral or consult
to engage with mental health services. Often, the primary care providers within the VA health
care system are the gatekeepers to access as consultation needs to be entered by that service. A
veteran can receive care through telehealth likely based on steps that are taken, and resources
available for that VA health care facility. This innovation will use the VTC capability as a means
of accessing the system and supporting quality intervention at first engagement with the Fresno
Vet Center.
The use of technology in the healthcare industry continues to grow. There are products
and applications now that monitor a person’s health 24/7. Some of the products that consumers
buy like a fit bit and other healthcare-related programs have the potential to collect large
amounts of data to identify potential risk factors. With the importance of data and medical
records, the use of Artificial Intelligence (AI) has grown to become a necessary resource for the
MILITARY AND VETERAN 47

health care industry (Nebeker, Torous, & Bartlett Ellis, 2019). With the growing importance of
technology use in the medical field, it is important that the Vet Center and other federal entities
evolve that serve those in the military community.
There are over 91 million smartphone users in the United States and over 1 billion users
worldwide as of 2011. (Wang, Park, Chung, & Choi, 2014). There has been large scale growth
in the number of programs that consumers can choose from on their smartphone devices. With
the number of smart devices, there were 17,000 medical-related application programs that were
made available to the public in 2010 (Wang et al., 2014). It will be important to understand the
preferences of the consumer regarding different programs to predict specific trends by those who
consume programs and services. Technology is paving the way to gather large scale data to
analyze trends and different demographics. Identifying different demographics of who will
consume the VTC innovation will be a key factor in targeting those of the military and veteran
community.
Project Implementation Methods
The first phase of the implementation will focus on the foundation. The Vet Center will
need a website that is specific to the facility. The purpose is to have a pilot program, and this
innovation can be duplicated at other sites. Have a collaborative with Vet Center leaders on
updating policy, and the functions of the program. The specific functions will need to be built
into the website that allows for the collection of veteran information, assessment, and feedback
on services provided. Without the website that is unique for the Fresno Vet Center the next step
with getting staff cannot be taken.
Then the second phase will come after the website has been created. The website will
need to be tested before the hiring of the clinicians. When the mock trials go smoothly with
MILITARY AND VETERAN 48

allowing vets to access the website, the tracking of data, and client records then the licensed
psychologists can be hired. There will be a Memorandum of Understanding (MOU) with the
licensed psychologist. All psychologists that are involved in the access point of the Vet Center
will have access to the Vet Center RCS Net program, and the VA electronic health records. With
increasing access, it will have future implications with the sharing of tools with other contractors
in local communities. There will be two licensed psychologists that will have term limits for the
pilot program innovation.
The use of value-based leadership can be applied in various settings in different positions
within each unique organization. With agencies and individual values align it has a positive
spillover for the consumer. When there are challenges, or dilemmas in any agency the values
support setting goals to work through those presenting issues (Alraqhas, 2015). An agency with
values allows for a roadmap that works well when those aspects work well for the individual
worker. There are core values that are instilled in people when they join the military. Those
values can be applied in real-time in the real world even post-military experience to overcome
obstacles. This innovation with the Vet Center that is a VA federal entity has values, and
standards that can guide workers toward a successful path. Implementing the vision of VTC
capabilities with the Vet Center will require deep-rooted values to advocate with leaders in the
organization for the delivery of service to consumers. It is important to remember individual and
organizational values to manage resistance when encountering barriers with executing the vision.
The use of technology can help all people regardless of age, gender, or ethnic
background. With specific perceptions and beliefs about technology continue to keep the elderly
population away from technology use. Supporting the elderly community with understanding the
value of technology can instill curiosity and the consumption of other services to promote quality
MILITARY AND VETERAN 49

of life. A large contributing factor with engaging the senior community with technology is the
individual’s willingness to be open to something new. There are several layers that create limits
with the senior community and internet usage, but it is important that computers are not new to
them. Also, the internet, social media, and access to technology is not necessarily new to the
senior community as they experienced the evolution of technological advances in their time as
well (Gilly, Celsi, & Schau, 2012). When considering this innovation with VTC and leveraging
technology to provide therapeutic services it is important to consider the senior population. There
are many Vietnam veterans that are consuming VA resources now especially as it pertains to
health-related issues, mental health, and life transitions that include exiting the workforce. There
is the potential for the Vietnam community to be more resistant to treatment using this method of
approach to care. However, there is hope for the senior community who did serve during
Vietnam with limited access and this technology may be a more viable solution for them when it
comes to logistical barriers with access to VA facilities.
There is a global mental health crisis as this has been the primary source of disability that
has surpassed any other chronic health issue worldwide. It is estimated that more than half of
those suffering from a mental health condition do not receive care, and suicide increased by 33%
from 2002 to 2015 globally (Insel, 2019). The use of digital phenotyping is a way for technology
to pick up on potential mental health risk factors through speech, or behavior thus has the
potential to trigger a response to a provider. Technology has the potential to reach those who
suffer from mental health issues, but some of the challenges have been with encouraging
engagement. There is technology that is getting developed for early intervention that can sense a
potential crisis allowing for an intervention to take place (Insel, 2019). Technology can address
gaps in the needs of the general population and will continue to evolve. There are plenty of
MILITARY AND VETERAN 50

alternatives if need be regarding this project and vision. Just the experience alone in research and
thinking creatively is the opportunity to seek opportunities strategically. It is critical to seek out
support and mentorship with passions to receive guidance from people who may be able to open
doors. In some cases, it could be a different door with a similar mission, or innovation. When
people have a similar mission or passion who has succeeded, they are likely to want to help. It is
important to keep an open mind when encountering barriers, limits, and resistance as there is so
much work that needs to be done for those who are suffering from mental health. There are no
limits when it comes to technology and there will always be a problem that needs to be addressed
where there are gaps regarding care. It could even be an unlikely alliance that opens the door to a
similar project just as Walmart was an unlikely partner for the VA.

MILITARY AND VETERAN 51

Financial Plans and Staging

The most expensive cost is the staffing of clinicians that are needed for innovation. There
will be three licensed psychologists that will have an 8-hour workday to cover a full 24-hour day
in a five-day workweek. This will require another three part-time psychologists to cover the
other two days of the week to have 24/7 coverage. The clinicians will require computers and
office supplies that will be provided by the local VA hospital IT service. There will be a cost for
marketing and advertising with some resources coming from the VA hospital system to support
with cost. With the facility that is hosting that is a federal agency there should be very little
ITEM DESCRIPTION COST IN-KIND SOURCE
REVENUE
Foundation Grants
Donations
Total Cash Received
Total In-Kind In-Kind Contributions
Total 665,000
EXPENSES
Personnel
Salaries & Wages

Psychologist 1, 2, & 3 full time 300,000
Psychologist 4,5, & 6 105,000
Subtotal 405,000
Fringe Benefits Calculated at 35% of Personnel Costs 141,750
Subtotal 546,750 0
OPERATING EXPENSES
Supplies & Material 5,000 5,000
Project Website Hosting 1,000
Software and Media Applications 1,000 5,000
Technology Computers & Equipment 5,000
Advertising 5,000 5,000
Subtotal 12,000 20,000
Personnel + Operating Expenses 558,750 100,000
Indirect Costs Negotiated Rate of 18% of Personnel + Operating Costs 100,575
Total Direct & Indirect Costs 659,325 100,000
NET Contingency 5,675
YEAR 1 BUDGET
MILITARY AND VETERAN 52

money available after it is allocated for the pilot project. The total requested for the innovation
will be $665,000 to make the innovation operational.
The general population has advocated for government agencies to be more effective and
have better accountability. These expectations that are placed on government agencies have been
in response to the national debt that services will make good use of resources through
performance evaluation. With the need to have oversight of resources federal agencies were
expected to produce financial statements that started in 1990 (Fadairo, Williams, Trotman, &
Onyekelu-Eze, 2008). Therefore, the Vet Center uses technology to measure performance and
collect data. The current performance goal for clinicians is to have 50% of direct client time
within working hours. It is imperative that agencies have goals, and standards to be accountable
to systems to show how the resources are utilized.
The use of performance appraisals is a way to encourage participation and accountability
with staff. Using the performance appraisal on staff is a tool for agencies to increase
performance. The delivery of a performance appraisal is a way for managers to provide feedback
to their workers. The perceptions by workers on the fairness of performance appraisals are
important as it can build trust with the system (Harrington & Lee, 2015). There is a connection
between performance appraisal and financial resources. The staff all cost an agency money, but
the return on the investment is using data metrics with measuring output. The appropriate policy
and the use of performance appraisals can encourage staff to perform to standards with
accountability with agency goals.

MILITARY AND VETERAN 53

Project Impact Assessment Methods are there specific measures

TAB Measures
Table 2: Specific Measures and Assessment Tools
Construct Measures
Point of
Measurement
Sources
Database collection
and tracking the
number of visits.
Every clinician should aim for
at least 50% direct client time.
Time
measured on
the clock for
clinician.
Face to face; over
the phone; and VTC
intervention all
applied to direct
client time.
Client Online Entry
Measure the amount of time
that it takes to engage with the
consumer. This will measure
point of entry and time
between prior to engagement.
The time will
start once the
veteran has
been verified
for services.
This will be done
through the updated
Vet Center website
that will host the
innovation.
Comparing Face to
Face and Online
Innovation
Measure if one intervention is
possibly preferred over the
other intervention. Measure
the differences with client drop
out rates.
Track the
amount of
time and visits
for each
different
intervention.
Face to Face
counseling and
Counseling live
online.
Use the number of
clients per clinician
as a justification to
add more staff
The goal will be to allow
clinicians to meet with clients
weekly if needed. The
continuous assessment of case
loads will be imperative for
quality of care.
A clinician
should not
exceed a
caseload of 20
veterans for
the fact there
is a 40 Hr.
work week
and there is a
50% direct
client time.
The RCS uses AI to
track and manage
output. The system
will show how many
clients that a
counselor will have,
so that will support
leadership when
there is a need for
more staff.
Measure the time
between the next
appointment.
This is to assess the quality of
care that service members and
veterans receive.

The time
between the
next
counseling
session.
The goal is for vets
and service
members to be seen
weekly regardless of
the method of
intervention. The
use of VTC has the
potential to address
workloads and save
on office cost.

MILITARY AND VETERAN 54

The Vet Center uses Artificial Intelligence (AI) for the database that tracks the output of
every clinician. Every clinician has a standard that is set by the agency that includes a 50% direct
client time, so that would equate to about 20 sessions per week. This innovation is about
effectiveness to allow the client to have options with receiving care. The Fresno Vet Center will
be the model that can be taken to scale and implemented with other Vet Center sites in the future.
The VTC technology will allow us to manage walk-ins at the facility, and those who chose to
access care with Fresno Vet Center Online. The Vet Center will measure the quality of care and
time before the individual's next session. Also, the dropout rate will be measured with face to
face in comparison to the intervention received through VTC innovation.
It is important to analyze other data when it comes to the project or the prediction of
potential future outcomes. The U.S. National War College has even been involved in the
research and probability predictions that have to do with military strategy and planning. The
analysis of evidence is often used to make predictions of outcomes (Friedman, 2019). When it
comes to providing an innovation to address specific gaps in services or targeting a specific
group it is necessary to do the research by identifying the needs. Having done the research on the
needs and looking at different demographics is a way to predict outcomes.
Stakeholder Engagement Plan
Some of the main themes that veterans, service members, supporters, and providers were
the difficulty with navigating some of these systems. The thing that is universal for the military
and veteran community is the need for resources, support, and information regardless of the
unique individualized presenting problems. There are several programs that exist to serve the
MILITARY AND VETERAN 55

military and veteran population, but there is a lack of coordination with these services that can
lead to confusion as additional barriers with accessing these resources (Winkel, 2017). It is
necessary that the Vet Center consider stakeholders as it expands capability and considers the
barriers that service members and veterans encounter. Having a better marketing strategy with
the VA to gain noticeability will be more useful in identifying the correct resources. The
dissemination of information on what, and how the Vet Center can be of service will be critical
when engaging consumers and working with community partners. The Vet Center working
toward having a better relationship with the active military component would be a way to
support those who will take the uniform off at some point in their lives. With the lack of success
that the transitioning classes have been having for the military community, it is time to consider
other options, and the Vet Center is a great option as a VA entity. However, it is important to
consider that the Vet Center is in a better place to provide services to those in the military as the
Readjustment Counseling Service (RCS) is not restricted to the scope of practice.
Having stakeholders involved in any sort of project, or research design are critical
especially when they are the key target population to receive a service or intervention. When
implementing an intervention in the infancy phase it is important to receive feedback and collect
information on how to proceed. When there is a study taking place, it is important that
participants understand the value of the process, and the goal of the intervention to increase
participation while reducing disengagement (Harrison et al., 2019). Any sort of study would
benefit involving stakeholders as especially if it will benefit other similar groups. In this case, the
stakeholder is the military and veteran population that is targeted for intervention. They will be
critical participants in the delivery and best practices for providing mental health services
through VTC capabilities.
MILITARY AND VETERAN 56

Communication Strategies and Products
The provider will be able to communicate with the veteran to live on a digital screen.
After a brief screening tool is used with the veteran to assess for the risk the veteran is then
placed in a queue. The veteran should not be placed in a holding queue if there is a psychologist
available. The use of sending links for invites to the portal is a way the clinician and veteran can
connect online when the clinician seeks to meet with the client for follow up.
Since 2001 there have been an estimated 2.5 million service members that have deployed
in support of combat operations (Wilson, Gettings, Hall, & Pastor, 2015). It is important to
consider the number of combat veterans that are being produced and the potential consequences
of these deployments. Often, we do not hear about the reality of how people enter the military or
the truth of what people have experienced that resulted in that person joining the service. The
fact is that there are many service members and veterans that do not come from the best home
situation as sometimes that is the motivating factor for joining the military. There is a large
number who will serve who may have undiagnosed existing conditions that make up the reality
of this demographic who have shouldered the burden of war. It is important to have this dialogue
within the media, DoD, VA, and other military-related channels to not take the sacrifices of those
that serve to be taken lightly. The dialogue and understanding of trends with the military are
important as these individuals who have deployed to the combat zone could come for the VA
system at any time. In an effort to be mindful of our history we must not make the same mistakes
and the lack of readiness that was experienced with the Vietnam population.
Ethical Considerations
As of 2015, approximately 69% of hospitals have some form of an online portal that
allows patients ease of use in the communication of health concerns, and access to their records
MILITARY AND VETERAN 57

(Lyles, Fruchterman, Youdelman, & Schillinger, 2017). Some groups of consumers may have
easier access to technology than other groups. When it comes to the development of healthcare-
related platforms there should be consideration given to how the program will function on
various devices to accommodate to user’s ability and resources available. In some cases, some
medical programs are in the need to further develop the simplicity of functions (Lyles et al.,
2017). With the growing use of technology in the health care field, it will be necessary to
consider some of the barriers that the consumer may face. Special considerations should be given
while developing programs regarding the limitations of the user. When it comes to innovation in
the health care field with the veteran community it will be important to consider the elderly
population and their ability to engage in their care.
With the use of technology in the healthcare field and increased access for the consumer,
there is a concern for potential data breaches. The health-related applications for smart devices
often consider the feedback from users, but there are concerns regarding the ability to safeguard
the information. The VA rolled out a PTSD application program for mobile devices that seeks to
collect data on the efficacy of that program (Barick et al., 2016). A federal agency is likely to
have more oversight than a private wellness agency for smart devices that are collecting data. As
the innovation with the implementation of VTC within the Vet Center system, it will be
necessary to consider safety while at the same time developing the intervention functionality to
increase ease of use through consumer feedback.
A one-year analysis of data indicates that over 60% of smartphone users used their device
to look up health-related information (Karcher & Presser, 2018). The use of texting with mental
health providers has become an increasingly popular way of communication. A mental provider
should consider potential breaches of a client’s device when delivering mental health services.
MILITARY AND VETERAN 58

The consumer of mental health services could be vulnerable to privacy risks through hacking, or
the loss of device used for receiving their care. It is recommended that consumers be aware of
the risks of using technology to receive their care through disclaimers, or through informed
consent. There are other privacy concerns as well when it comes to meeting with clients through
a live video feed that may result in others possibly hearing the conversation (Karcher & Presser,
2018). The technology advances have increased access to care and communication with various
providers and settings. It is necessary that providers stay current with the different potential risk
factors associated with ease of use and any unintended consequences that may cause harm to the
consumer. As this innovation progresses to use VTC capabilities within the Vet Center it will be
important to be mindful of the potential consequences that increase access can have on those
who consume services through technological advances.
Area 5. Conclusions, Actions, and Implications
Summary of Project Plans
The hosting Vet Center will use the VTC program to manage new clients seeking to
access services. This allows for the clinicians that are already working on-site to have fewer
interruptions. The innovation is expected to improve the quality of care for existing clients, and
to set a new standard for those seeking services. If the innovation does what it is intended to do,
then it can be duplicated at other Vet Center sites. The pilot program with VTC will need to
show proof of concept to go forward and have the innovation taken to scale.
The surgical community used technology to communicate and provide supervision in the
1960s. This was used to provide mentorship using videoconferencing when there were logistical
challenges with consultation (Augestad et al., 2017). The concept of this technology to
communicate is not something new. As technology has evolved it is necessary to use in the
MILITARY AND VETERAN 59

healthcare industry, especially for the military and veteran community. Just as this technology
has been used for consultation in the past there is the benefit that it can be used with consumers.
Those who encounter the most barriers with access to care have been the greatest
supporters of innovative technological interventions with providing care. With the growing
popularity of technology in health care, it promotes the engagement of mental health services
through telehealth by meeting live with clients through a screen (Lin et al., 2019). It will be
necessary going forward to further assess the needs of the military and veteran population.
Staying current on limitations and barriers to care as it pertains to the military community is an
opportunity for new programs.
Current Practice Context for Project Conclusions
There is the potential for technology to identify health risks in a person prior to even
meeting with a provider. The use of technology has the potential to reduce the burden of client
load on medical providers by allowing technology to do most of the screening for routine issues.
The potential for technology in the health care field can create better access to care for the
consumer (Timmis & Timmis, 2017). Technology has the potential to increase capabilities for
consumers and providers regardless of the setting or discipline. Even though some agencies are
providing care using technology it looks different by each agency. In the mental health field,
their agencies are leveraging the use of technology by meeting with clients through a screen.
Meeting with veterans and service members through a screen is something that is getting done,
but not at full potential.
Project Implications for Practice and Further Action
A lawsuit was filed in federal court by thousands of Navy and Marine veterans in
response to the less than honorable discharges that were mental health-related. Most veterans
MILITARY AND VETERAN 60

involved in the lawsuit felt that they were punished for minor infractions in the military that were
associated with mental health symptoms. The fact that these service members were given less
than honorable discharges it creates a barrier with some of the VA benefits (Collins, 2018). The
implications with the handling of military mental health and misconduct have applied pressure to
the VA system as these veterans return to their communities. The Vet Center criteria has been
Combat, or MST to receive services. Vet Center services have been available for those who have
less than honorable discharges and those who experience VA health care eligibility issues. The
Vet Center can provide mental health counseling and support the veteran with the service
connection process. The service-connected disability has monetary, state, federal, and medical
resources that are associated with the disability percentage.
Approximately 45 percent of those who are returning from conflict is engaging in
resources that provide compensation for service-connected related injuries (Hayden & Buzzetta,
2014). A service member returning home who has a mental health condition is likely to have
difficulty with functioning in some daily tasks that make it difficult to transition into civilian life.
Having meaningful employment post-military service will depend on the veteran’s severity of
impairment level to manage certain challenges that are associated with the transitioning process
(Hayden & Buzzetta, 2014). The implications of this innovation have the potential to support the
transitioning process in the military with the active-duty component of the military. This is
because there is the possibility for a counselor to have an engagement with a person prior to
getting out of the service. The Vet Center is the main federal counseling entity under the VA that
provides therapeutic counseling services to the active-duty component. It will be a strategic
move for the Vet Center to be more actively engaged in serving those who are still in the military
using VTC technology.
MILITARY AND VETERAN 61

The consequences of mental health risk factors that include suicides are at catastrophic
levels. It is often that those with the most significant need for mental health services experience
the greatest limitations with receiving care (Manderscheid, 2019). Those who experience the
greatest hardships are likely to have fewer resources with engaging in services. Technology is
necessary for the delivery of care to those who encounter barriers. If mental health is such a big
problem, then we need to do more even if it means scaling some programs.
Project Limitations
The mental health providers that use technology to deliver interventions are responsible
to the consumer for privacy and confidentiality. There are some difficulties with providing
services that have some level of risks with providing interventions through the method of web-
based programs. The use of telehealth services did not come around until the 1960s that
consisted of microwaves and television from distances that were restricted from 2 to 20 miles
(Lustgarten & Colbow, 2017). It was not until the 1990’s that technology and the use of the
internet could prove to be of value to providers, businesses, and consumers (Lustgarten &
Colbow, 2017). In more recent times some providers have used the limitations and consent
forms to cover any associated risk factors with providing telehealth services through the internet.
When the delivery of mental health services takes place live through web-based services face to
face there is the concern of other parties gaining access other than the standard concerns as a
therapist (Lustgarten & Colbow, 2017). Federal Agencies use encrypted technology when it
comes to providing care through technological resources. The use of telehealth or Video
teleconferencing technology has come a long way since the 1960s. Mental health providers can
provide services often within the same state associated with provider license, but that differs
when operating under a federal agency.
MILITARY AND VETERAN 62

The digital capabilities have changed the traditional means of the provider and consumer
experience. It is anticipated that by 2022 the use of technological ease of use in mental health
and wellness will expand significantly (Lustgarten & Elhai, 2018). There are concerns for the
mental health profession as doctoral students often do not receive any training with the use of
providing interventions online, the ethical and legal concerns in telehealth are important
considerations with as much as 72% recent Psychiatric Residences expressed interest in the
delivery of this method when providing client care (Lustgarten & Elhai, 2018). About one-third
of clinical psychologists have transmitted communication regarding client care through
unsecured email transmissions. Also, an estimated 20% of mental health providers had used cell
phones to communicate with clients who did not have password protection (Lustgarten & Elhai,
2018). There are real concerns when considering client care and confidentiality. There is still
more room to go with the private sector and providers who work independently using
technological advances. The Vet Center is a federal entity that can provide services through
encrypted capabilities.

MILITARY AND VETERAN 63

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Abstract (if available)

Abstract This paper will focus on the military and veteran community. The focus is on how technology can be leveraged to provide care with the veteran community. Some of the limits that impact the veteran community with access to care will be indicated. The innovation leveraging technology will be used to decrease barriers with access to mental health care. There will be further discussion with how technology can be used to address gaps in services.

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Asset Metadata

Creator Castro, Adam James (author)

Core Title Military and veteran

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 01/08/2020

Defense Date 12/31/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag behavioral health,innovation,intervention,Mental Health,Military,military risk,military suicide,OAI-PMH Harvest,policy,practice,risk factors,Technology,telehealth,veteran

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lee, Nani (committee chair)

Creator Email adamcast@usc.edu,castro.adam259@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-260797

Unique identifier UC11675204

Identifier etd-CastroAdam-8108.pdf (filename),usctheses-c89-260797 (legacy record id)

Legacy Identifier etd-CastroAdam-8108.pdf

Dmrecord 260797

Document Type Capstone project

Rights Castro, Adam James

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA