Military Exposures and the Aging Veteran What Long-term Care Providers Need to Know

Omowunmi Osinubi, MD, M.Sc. MBA., FRCA, ABIHM, IFM-CP, BCN. Director, Clinical Services War-related Illness & Injury Study Center Department of Veterans Affairs – New Jersey Healthcare System [email protected]

The National Association of State Veterans Homes Summer Conference Denver, Colorado August 8, 2019

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center

The views expressed in this presentation are those of the presenters and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

There are no financial conflicts of interest to disclose.

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center Presentation Outline

• Introduction to VA Post Deployment Health Services (PDHS/WRIISC) • War Exposures & VA Presumptive Conditions • Gulf War Exposures & VA Presumptive Conditions • Garrison exposures: – Camp Lejeune & VA Presumptive Conditions – Training-related exposures • Mental Health & Cognitive impacts of Military Exposures • Available Resources

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center Post Deployment Health Services Mission:

• A VA-Delivered Core Service that assesses the impact of deployment/ environmental exposures on Veterans and develops related policy, research, education and health care strategies

• PDHS consists of three interrelated Programs: – Environmental Exposure Epidemiology – Environmental Health (Pre-911 Programs / Post-911 Programs / Radiation dose evaluations) – The War Related Illness and Injury Study Center • WRIISC is a National VA Post-Deployment Health Program, established by Public Law 105-368, 105th Congress, 1998

4 Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WRIISC LOCATIONS & SERVICE AREAS

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WRIISC MODEL

Research Research produces knowledge and evidence- supported interventions and tools that can improve patient care and can be packaged and disseminated through education activities.

Education Clinical Care Education of patients and Observations from clinical care providers can improve patient lead to research questions and outcomes and identify gaps in testable hypotheses, highlight knowledge to be addressed gaps in provider and patient by research. knowledge.

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TODAY’S VETERANS – AGING POPULATION

19.6 Million Veterans in The USA 55% of all Veterans are 60 years old or older M Younger than 30 1

M 33-44 years old 3.3

45-59 years old 5.7 M

60-74 years old 7.7 M

75 years or older 4.8 M

0 2 4 6 8 10

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center THE : 11/1/55 – 4/30/75

• Long, costly and divisive conflict

• U.S. DoD estimates that for the years 1955–1975: – 2.8 million served in Vietnam – 3.4 million served in Southeast Asia – 8.7 million served worldwide.

• More than 3 million people died – More than 58,000 Americans – More than half of the dead were Vietnamese civilians

• January 1973 US & North Vietnam concluded peace agreement

• Vietnam Veterans returned home to negative reactions - along with physical damage including the effects of exposure to the toxic herbicide . – https://www.history.com/topics/vietnam-war/vietnam-war-history

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHAT IS AGENT ORANGE (AO)?

“Agent The dioxin Orange” was a by- An herbicide A mixture of Contained came from product of that was two TCDD orange strip the used to kill common (dioxins) on drums manufacture plants herbicides contaminant (Also other of the colors) herbicide

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHEN WERE HERBICIDES USED?

• Herbicides used from 1961 to 1971 • Agent Orange 1965 – ‘70; Green, Pink, Purple ’61 – ‘65 • Agents White and Blue: 1960s – ‘71 • Agent Orange in Korea along DMZ from 1968 to 1971

‘61 ‘65 ‘68 ‘69 ‘70 ‘71 Herbicide

Agent Orange in Vietnam

In Korea

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHY WAS AGENT ORANGE USED?

• Tactical herbicides - used to defoliate forested and rural land • Goals of defoliation: – Deprive guerillas of cover – Deprive guerillas of their rural support and food supply • By destroying ability of peasants to support themselves in the countryside, forcing them to flee to U.S. dominated cities

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHAT WAS THE EXTENT OF HERBICIDE USE?

• 20 million gallons of defoliant sprayed from aircraft

• USAF Operation Ranch Hand: 6, 542 spraying missions

• >20% of ’s forest sprayed over 9 years

• By 1971, 12% of total area of S. Vietnam sprayed

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center OTHER AGENT ORANGE EXPOSURE LOCATIONS

• May have been exposed in: – Thailand near perimeter of certain bases ~1961-75 – Contaminated C-123 air planes from ~1969 – 86 – Herbicides stored or tested elsewhere – Brown Water if on land/inland waterways ~1962-75

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHAT IS THE ?

• Public Law 102-4 (Agent Orange Act of 1991) – Established presumption of exposure & service connection for diseases associated with herbicide exposure – Institute of Medicine (IOM) reviews Agent Orange research and makes scientific recommendations to VA – Secretary of VA uses IOM Reports to inform decisions regarding conditions to put on the VA List of conditions Presumed Related to Agent Orange.

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center VA PRESUMPTIONS: WHY DO WE HAVE THEM?

• Lack of exposure data and real knowledge • Two-step presumption:

If you were there…. You were exposed

If you were exposed and develop one of the conditions…. It is related to the exposure

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center NATIONAL ACADEMIES OF MEDICINE (NAM) VETERANS & AGENT ORANGE REPORTS

•Funded by VA to determine if health effects are associated with exposures to herbicides and dioxin.

•Eleven reports published by Institute of Medicine (IOM), now called the National Academies of Medicine (NAS).

•Update 11 published in Nov 2018 - available free online at:

http://www.nationalacademies.org/h md/Reports/2018/veterans-and- Released in agent-orange-update-2018.aspx November 2018

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center A O - TIME LIMITED PRESUMPTIVE CONDITIONS

• Peripheral Neuropathy (early onset) • Porphyria Cutanea Tarda • Chloracne (or similar acneform disease)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center AGENT ORANGE PRESUMPTIVE CONDITIONS:

• Cancers: – Chronic B-Cell Leukemias – Hodgkin’s Disease – Non-Hodgkin Lymphoma – Multiple Myeloma – Some Soft Tissue Sarcomas – Prostate Cancer – Respiratory Cancers: • Lung, larynx, trachea, bronchus

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center AO PRESUMPTIVES: COMMON AND UNCOMMON

• Common: - Parkinson’s Disease - Ischemic Heart Disease - Diabetes Type 2

• Uncommon: - AL Amyloidosis - Spina Bifida (Vietnam or Korean DMZ) - Birth Defects (children of female Vietnam Vets)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center BLUE WATER NAVY (PROCOPIO V. WILKIE)

• The term refers to those vessels usually navigating outside the territorial seas of Vietnam. – BWN within 12 miles from shore

• Blue water Veteran with prostate cancer and Type II diabetes filed a law suit against the VA

• U.S. Court of Appeals for the https://www.militarytimes.com/news/pentago Federal Circuit has ruled that VA n-congress/2019/01/29/court-rules-va-must- pay-disability-benefits-to-blue-water-vietnam- must pay disability benefits to veterans/ ‘blue water’ Navy Vietnam veterans

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center www.va.gov/opa/pressrel/pressrelease.cfm?id=5280

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHAT’S AHEAD: NATIONAL ACADEMIES OF SCIENCE

• Veterans and Agent Orange Update 2014: – Limited evidence of suggestive association for: • Bladder Cancer • Hypothyroidism • “Parkinson-like Symptoms”

• Veterans and Agent Orange: Update 2018: – Sufficient evidence of association for • Hypertension • Monoclonal gammopathy of undetermined significance (MGUS)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHAT’S AHEAD:

• NAS Report on Intergenerational Effects of Toxic Exposures from Military Service – Gulf War Veterans – Vietnam Veterans – Recommend a strategy for studying any effects in children of future Veterans

• Ongoing Studies: – Army Vietnam-Era Veterans Health Study – Air Force Health Study – Vietnam Era Health Evaluation Retrospective (VE – HEROeS)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center 1990-1991 GULF WAR

• International Conflict in Response to Iraq’s Invasion of Kuwait

• SW Asia Theater of Operations: Persian Gulf, Red Sea, Gulf of Oman, Gulf of Aden, portion of the Arabian Sea, Iraq, Kuwait, Saudi Arabia, Oman, Bahrain, Qatar, UAE

– Operation Desert Shield (8/1990 –1/1991) • Coalition of 34 nations military build up

– Operation Desert Storm Began 1/17/91- • Coalition attacks on Iraqi forces with massive 6 week air and naval bombardment campaign

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TIMELINE GULF WAR THROUGH OEF/OIF/OND

August 1990 January 1991 February 1991 March 1991 June 1991 November 1991

• Iraq invades Kuwait; US responds

• 700,000 US service members deployed

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TIMELINE GULF WAR THROUGH OEF/OIF/OND

August 1990 January 1991 February 1991 March 1991 June 1991 November 1991

• Air war begins 1/17/1991

• 700 oil well fires: toxic smoke

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TIMELINE GULF WAR THROUGH OEF/OIF/OND

August 1990 January 1991 February 1991 March 1991 June 1991 November 1991

• Ground war begins on (2/23/91)

• SCUD missile attacks – Dhahran attack killed 25 US soldiers • 100-Hour War – Most Iraqi soldiers fled or surrendered • Cease-fire (2/28/1991)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TIMELINE GULF WAR THROUGH OEF/OIF/OND

August 1990 January 1991 February 1991 March 1991 June 1991 November 1991

• 3/3 – 4/6/1991

• Khamisiyah Weapons Depot destroyed

• nerve gas canisters detonated

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TIMELINE GULF WAR THROUGH OEF/OIF/OND

August 1990 January 1991 February 1991 March 1991 June 1991 November 1991

• Most troops return home

• Some reported to Saudi Arabia: - Machinery Cleaning

• June 13, 1991

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TIMELINE GULF WAR THROUGH OEF/OIF/OND

August 1990 January 1991 February 1991 March 1991 June 1991 November 1991

• Last oil well fire extinguished

• No end date for Gulf War service is currently specified…

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center TIMELINE OF MORE RECENT CONFLICTS

AFGHANISTAN IRAQ

•OEF: Operation Enduring • OIF: Operation Iraqi Freedom Freedom – 10/7/2001 – 12/28/2014 – 3/19/2003 – 8/31/2010

• OND: Operation New Dawn •OFS: Operation Freedoms - 9/1/2010 – 12/15/2011 Sentinel

- 1/1/2015 – Present • OIR: Islamic State - Operation Inherent Resolve - 10/15/2014 – Present

Source: https://fas.org/sgp/crs/natsec/RS21405.pdf

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center 1990-1991 GW: LOW CASUALTY & HIGH MORBIDITY

• 700,000 US troops deployed ($61B in 1991)

• Total US casualties = 292 (0.04%) – 147 on battlefield; 145 non-battle-related causes

• US troops with GW-related illnesses ($400B) – 25% to 35 % or 175,000 to 250,000 soldiers – US Army & Marine Corps > Navy & Air Force – Enlisted > Officers – Females > Males – Highest rates in troops in forward areas

• 27 Out of 28 GW coalition countries report GWI in their troops.

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center GULF WAR EXPOSURES

Physical/Psychological Heat/Cold Injuries, Incoming Fire, Explosions, and Blasts, Musculoskeletal Injuries, Loud Noises, Psychological and Mental Stressors

Chemical Oil Well Fires, Burn Pit Smoke, Sand/Dust Storms, Industrial Air Pollution, Petrochemical Solvents and Fuels, Depleted Uranium, CARC Paint, Pesticides, Chemical Weapons

Prophylactic Measures Anthrax Vaccine, Smallpox Vaccine, Antimalarial Prophylaxis (Mefloquine, Doxycycline), Pyridostigmine Bromide Pills, DEET/Pesticides

Biological Animal/Insect Bites, Infectious Agents, Blood/Bodily Fluids, Biological Weapons

REF: WRIISC clinical reports, www.publichealth.va.gov

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WHAT IS GULF WAR ILLNESS? (National Academies of Science)

“Characterized by chronic, unexplained conditions and/or constellations of symptoms and illnesses that are not explained by established medical/psychiatric diagnoses or standard laboratory tests”.

• Symptoms vary widely with combinations of: widespread pain, muscle aches, headache, memory/thinking problems, fatigue, breathing problems, stomach & intestinal symptoms, skin abnormalities.

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center VA DEFINITION GULF WAR VETERANS’ CHRONIC MULTISYMPTOM ILLNESS

• VA presumes chronic unexplained symptoms existing for ≥ 6 months are related to Gulf War service without regard to cause.

• These "presumptive" illnesses must have appeared during active duty in the Southwest Asia theater of military operations; or by December 31, 2021, and be at least 10 percent disabling. These include but are not limited to: – Myalgic Encephalomyelitis/Chronic Fatigue Syndrome – Fibromyalgia – Functional Gastrointestinal Disorders – Undiagnosed Illnesses • Including but not limited to: abnormal weight loss, fatigue, cardiovascular disease, muscle and joint pain, headache, menstrual disorders, neurological and psychological problems, skin conditions, respiratory disorders, and sleep disturbances

– https://www.publichealth.va.gov/exposures/gulfwar/medically-unexplained-illness.asp

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center SOUTHWEST ASIA THEATER OF MILITARY OPERATIONS

For VA benefit purposes, GW service is active military duty in any of the shown areas, at any time from 8/2/90 to present.

–Includes more recent conflicts in Iraq (OIF/OND/OIR) –Excludes Afghanistan (OEF)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center GWI/CMI: MOVING FORWARD

• Unfortunately, we cannot undo exposures that occurred in the past.

• There is no cure for CMI/GWI.

• There are strategies and treatments that can help Veterans manage their symptoms and improve their overall quality of life

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center VA/DoD CLINICAL PRACTICE GUIDELINES FOR CMI

Consider non-opioid analgesics or acupuncture. Consider a trial of SNRI. Pain predominant Consider Tramadol symptoms Consider TCA, SSRI or Pregabalin may also be considered

Fatigue Consider acupuncture. predominant Consider trial of SNRI or TCA. symptoms Do not use steroids, antivirals or antibiotics. Avoid stimulants.

Consider minimal contact psychological therapies. Gastrointestinal Treat in accordance with recognized evidence-based Predominant care for irritable bowel symptoms (IBS). symptoms Do not use acupuncture.

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center GARRISON EXPOSURES: CAMP LEJEUNE

• U.S. Marine Corps training base in North Carolina

• 1950s to 1980s: – Water supply was contaminated with volatile organic compounds

• Over 1 million individuals potentially exposed to contaminated water

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center

SOLVENTS IN CAMP LEJEUNE WATER

• Toxic chemicals at concentrations 240 to 3400 times safety standards:

– Tetrachloroethylene (PCE/PERC) – Trichloroethylene (TCE) – Benzene – Vinyl chloride – Trans 1,2-dichloroethylene (1,2-tDCE) breakdown product from TCE/PERC break down

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center LOCATIONS OF EXPOSURE

HB: 06/1978 & 01-02/1985 and dry spring/summer months

TT: Exposed to PERC HP: Exposed to 1957-87 TCE but also PERC, DCE, VC and Benzene 1953 – 85

TT: Tarawa Terrace HB: Holcomb Blvd. HP: Hadnot Point

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center www.va.gov/COMMUNITYCARE/programs/dependents/CLFMP.asp

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center CAMP LEJEUNE PRESUMPTIONS

• The VA has established a presumption of service connection for 8 diseases for Veterans:

– Adult leukemia – Aplastic anemia/myelodysplastic syndromes – Bladder cancer – Kidney cancer – Liver cancer – Multiple myeloma – Non-Hodgkin's lymphoma – Parkinson's disease

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center https://www.publichealth.va.gov/exposures/camp-lejeune/

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center DEPLOYMENT EXPOSURES & MENTAL HEALTH

Vietnam – Draft, deployment substance use, pre-PTSD & TBI awareness, reception, Agent Orange

Gulf War I – Highway of Death, bulldozer assault, Khamisiyah, chemical alarms, missiles, oil-well fires, PTSD

Post-9/11 Iraq & Afghanistan Wars – Blast exposures, suicide bombings, drones, counterinsurgency, burn pits, mefloquine, PTSD

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center AGING AND PSYCHOLOGICAL TRAUMA

• PTSD symptoms can: – Begin soon after war and persist until older age – Emerge in older adulthood – Begin at time of trauma exposure, decrease over time, and worsen again in later life • PTSD symptoms may increase with: – Retirement – Medical illnesses and physical decline – Current wars triggering past memories – Decreased self-medicating with alcohol or drugs • Later-Adulthood Trauma Reengagement

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center

POST-DEPLOYMENT MENTAL HEALTH: BEYOND PTSD

• Posttraumatic stress • Grief • Insomnia • Panic attacks • Anger • Sleep Apnea • Dissociative • Moral Injury • Sexual Dysfunction symptoms • Impact of killing • Chronic Pain • Depression • Spiritual concerns • Traumatic brain • Bipolar disorder • Existential concerns injury • Generalized anxiety • Betrayal • Neurocognitive • Obsessive- • Suicidality disorders, dementia

5 Diagnoses 5 compulsive disorder • Homicidality • Poorer physical

- health • Intermittent • Self-injury

explosive disorder Comorbidities • Intimate partner • Psychotic symptoms violence • Eating disorders • Social isolation • Alcohol and • Adjustment to substance use disability disorders Concerns Additional

• Vocational issues Primary DSM Primary

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center BLAST EXPOSURES & TBI

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center MILITARY OCCUPATION/TRAINING EXPOSURES THAT MAY AFFECT COGNITION

• Explosive ordinance Blasts disposal • In-flight re-fueler Solvents • Paratrooper Whiplash & blows • Diver Diving injury • Gunner Heavy weapon blasts • Aircraft mechanic Solvents • Motor transport Motor vehicle operator accidents

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center MILITARY OCCUPATION EXPOSURES FROM MUNITIONS Slide courtesy of J Schatz/G. Dardia (Department of Defense)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center NEUROTOXINS MILITARY AND/OR CIVILIAN EXPOSURES

• • Carbon disulfide •Lead • N-hexane •Manganese • Methyl butyl ketone •Mercury • Perchloroethylene •Tin • Toluene • Trichloroethylene

Metals Solvents

Insecticides Toxic Gases

•Organophosphates • Ethylene oxide •Carbamates • Carbon monoxide • Carbon disulfide • Sulfur dioxide

Feldman RG (1999): Occupational & Environmental Toxicology. Philadelphia, PA: Lippincott-Raven

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center APPLYING CURRENT KNOWLEDGE TO PAST EVENTS • 1990-1991 Gulf War Veterans who report TBI ↑ rates of chronic multi-symptom illness

• Veterans with mild TBI with LOC 2.5 times adjusted hazard ratio for dementia • Veterans over 55 with a TBI diagnosis 60% ↑ risk of developing dementia over 9 years

• Male Gulf War I era Veterans who applied for VA PTSD benefits 18-21% reported experiencing military sexual trauma during 1990-1991

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center SUMMARY

Vietnam War – Parkinson’s disease, Agent Orange-related cardio- metabolic & cerebrovascular risk factors, PTSD Gulf War I – Gulf War illness, fibromyalgia, chronic fatigue syndrome, TBI, PTSD, Neuro-immune toxicity Post-9/11 Iraq & Afghanistan Wars – TBI, PTSD, Gulf War illness, Neuro-immune toxicity Garrison: Camp Lejeune and/or Military Training – Cancers, solvent and/or heavy metal toxins and carcinogens & possibly neurobehavioral conditions

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center DEMENTIA RISK FACTORS

• Age • APOE ԑ4 allele status Agent Orange exposure • TBI • PTSD • Depression • Sedentary lifestyle Gulf War • Vascular risk factors: chronic multisymptom – Smoking illness – Hypertension – Type II diabetes – Obesity – Metabolic syndrome – Coronary artery disease Risk factors elevated – Stroke in military and – Hyperhomocysteinemia Veteran populations – Dyslipidemia – Chronic kidney disease

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center OTHER FACTORS IMPACTING COGNITION & AGING

Sleep

Medications Cognitive & Substance Reserve Use

Social Nutrition & Support Gut Health

Mental Exercise Health

Pain

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center ROLE OF LONG-TERM HEALTHCARE PROVIDERS

• You may be the first person asking the Veteran about a specific exposure

• This may be the first time a Veteran is disclosing their traumatic event(s) to a health care provider

• Your response to the patient can make the difference between access to more services vs. unmet health needs

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center MENTAL HEALTH - HELPFUL HINTS

Listen and believe

Avoid stigmatizing language

Do not minimize the impact of military traumas or exposures of concern

Hold hope for the future

Unconditional positive regard

Debrief and consult with colleagues/appropriate specialists

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WRIISC REFERRALS – WHO IS ELIGIBLE

Any deployed Veteran with a complex health condition and no known cause: Medically unexplained symptoms, e.g. Chronic multi-symptom illness (CMI) or Gulf War Illness (GWI)

Veteran has been thoroughly evaluated by their Primary Care Provider (PCP) but specific questions remain unanswered

Any Veteran who has had many tests and/or treatment with little to no symptom improvement

Any Veteran with possible deployment-related environmental exposure problems or concerns possibly related to their health symptoms – those you may also see that still require additional assessment or have concerns

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WRIISC CLINICAL SERVICES

Interdisciplinary team approach to address complex symptoms related to deployment. Comprehensive Environmental WRIISC E- Interdisciplinary Exposure Consults Evaluations Assessments

• Thorough medical • 3-5 day visit with • Assesses potential record review WRIISC clinical contribution of • Diagnostic team; Some exposures to impressions diagnostic testing Veteran health • Tailored • Provides diagnostic concerns as a recommendations impressions and a component of for next steps “road map” of comprehensive evaluation • Engages provider(s) tailored and Veteran recommendations to • Stand-alone service improve function with telephone and quality of life consults available • Enhanced Airborne Hazards Evaluation

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WRIISC CLINICAL: HOW WE CAN SUPPORT YOU

• Ask us general questions – eQuery available through our website • Formal inter facility consults (IFCs) – eConsults are perfect for a patient-specific question • Best Practices – Contact us with questions about how to address patient concerns (e.g., GWI, burn pit/airborne hazards or other toxic exposure related issues)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WRIISC EDUCATION Continuing Education Webinars For Providers 13 Webinars in FY18 - 3,390 attendees; 12 for FY 19 7 Accredited for delivery in TMS and 5 TRAIN.org

E-learning Modules (on–demand) for Providers Web-based on Airborne Hazards, Environmental Exposure Assessments, Gulf War Illness and Newest is on Chronic Multisymptom Illness for VA providers on TMS and for community providers on TRAIN.org

WRIISC Website www.WarRelatedIllness.va.gov 116,719 views in FY 18

Newsletters & Factsheets Newsletter over 28000 distributed within Veteran community Factsheets 7500+ downloaded/distributed

In Person and Telehealth Classes For Veterans Agent Orange, Airborne Hazards, Gulf War Exposures, Camp Lejeune, Mindful Meditation (phone based)

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center ON-DEMAND ACCREDITED EDUCATION FOR PROVIDERS

• Recorded Webinars on TMS and TRAIN.ORG for VA and Non-VA Providers – WRIISC-PDHS: Airborne Hazards Registry Updates and Outreach Activities – WRIISC-PDHS: Airborne Hazards Research Findings and Clinical Applications- TMS only – WRIISC-PDHS: Communicating With Veterans on Deployment-Related Exposure Issues – WRIISC-PDHS: Garrison Exposures – TMS only – WRIISC-PDHS: Military Cultures - Experiences, Reintegration, and Whole Health – WRIISC-PDHS: Post-9/11 Deployment-Related Exposures – WRIISC-PDHS: Pre-9/11 Deployment-Related Exposures

• E-learning Modules for VA and Non-VA Providers on TMS and TRAIN.org: – MOD 1: Assessing Deployment Related Environmental Exposures – MOD 2: Airborne Hazards – MOD 3: Gulf War Illness – Mod 4: NEW!!! Chronic Multi Symptom Illness

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center WAR RELATED ILLNESS & INJURY STUDY CENTER

Home Page https://www.warrelatedillness.va.gov/

Clinical Services Inter Facility Consult (IFC) process in VA’s CPRS https://www.warrelatedillness.va.gov/WARRELATEDILL NESS/clinical/index.asp

Webinar Series https://www.warrelatedillness.va.gov/WARRELATEDILL NESS/education/webinars/save-the-dates-2019.asp

63 Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center Additional Websites

Post Deployment Health Questions: https://www.publichealth.va.gov/exposur es/index.asp

Toxic Environmental Exposure Questions: https://www.publichealth.va.gov/exposur es/index.asp

64 Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center ACKNOWLEDGEMENTS: NJ WRIISC TEAM

Physicians Nurse Practitioners Cardiopulmon ary laboratory Complementar staff y and Environmental Integrative Exposure Medicine Specialists Specialists WRIISC Leadership Admin Core Education and Research Core Psychologists Risk and Neuro- Communicatio Psychologists n Specialists

Social Workers

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center QUESTIONS?

[email protected] 800-248-8005

Office of Patient Care Services Post-Deployment Health Services War Related Illness and Injury Study Center