Cultural Competency Starts with Being Informed. Oregon Health and Social Service Workers Who Understand Active Duty and P

Cultural competency starts with being informed. Oregon health and social service workers who understand active duty and prior-service military personnel and their families have a better chance of effectively helping their clients.

Statistics Statistics (taken from ODVA website and the US Census Bureau, which work off of 2010 numbers):

• More than 333,800 veterans are living in Oregon. • 249,486 veterans are ages 50 or older. • 84,314 veterans are under 50 years of age.

Top 10 veteran-populated Oregon counties: 1. Multnomah (50,014) 2. Washington (37,336) 3. Clackamas (33,317) 4. Lane (33,379) 5. Marion (26,868) 6. Jackson (24,856) 7. Deschutes (15,578) 8. Douglas (14,345) 9. Linn (12,868) 10. Josephine (11,310)

Out of those 333,800 veterans, only 27% access Veteran Affairs. Two-thirds of the veterans in Oregon are unaccounted for at the VA, which means they are not engaged in VA services and therefore the VA does not know where they are.

Military Groupings

Fire and maneuver team: 2 people Company, squadron: 70-250 people Fire team: 4-5 people Battalion: 300-1,000 people Squad or crew: 8-16 people Regiment: 2,000-3,000 people Section or patrol: 8-12 people Brigade: 2,000-5,000 people Platoon: 25-60 peolple Division: 10,000-20,000 people

did you know? Two-thirds of the veterans in Oregon are unaccounted for at the VA, which means they are not engaged in VA services and therefore the VA does not know where they are.

Page 1 Discharge

Type of Discharge Type of Punishment Eligible for… Not eligible for… Honorable All benefits. General, Under Mandatory if drugs are Medical, compensation GI Bill (usually) and Honorable Conditions involved. Non-judicial and pension. possibly other benefits. punishment. Other than Honorable Convicted by civilian Some medical in some Most benefits. court. Cannot re-enlist. cases. Bad Conduct Court martial. Usually None. Most benefits. involves confinement in military prison. Dishonorable General court martial None. Anything. (desertion, sexual assault, murder). Can't own firearms. May lose right to vote.

Structure of Veterans Affairs Federal: U.S. Department of Veteran Affairs

State: Oregon Department of Veteran Affairs (ODVA) • Vet Centers-Predominantly counseling services. • Vet Medical Centers-Full service center for all things VA. • Community Based Outpatient Center (CBOC)-Predominantly medical services.

County: Veteran Service Officers (CVSOs)-They are not a part of the VA but they work in partnership with ODVA. CVSOs work with veterans to assist in navigating resources and benefits that may be entitled to the individual asking for assistance. They also are resources for county-specific agencies and programs that are non-VA affiliated and that may serve veterans.

Localized Service Organizations such as American Legion, DAV (Disabled American Veterans), etc.: These services are usually non-profit organizations created as mutual aid/peer-to-peer support. The services range from social activities and support to basic needs, benefits assistance and advocacy.

There are 23 VA facilities in Oregon; all but three are in the western half of the state. The eastern half has two: One in Umatilla County and one in Harney County (see map list of facilities in Oregon).

Understand the Veterans Health Administration Who is eligible?

To be eligible for VA medical benefits, a veteran must have served in the active military, naval, or air service or must have served as a Reservist or National Guard member called to active duty (for other than for training) and must have completed the full call-up period. The veteran must have been honorably discharged or released. Veterans who enlisted after Page 2 September 7, 1980, or who entered active duty after October 16, 1981, must have served 24 continuous months, or the full period for which they were called to active duty, in order to be eligible. This minimum duty requirement may not apply to veterans discharged for hardship, early out, or a disability incurred or aggravated in the line of duty. If a veteran meets those basic requirements, he or she can receive VA medical benefits regardless of income or net worth if one or more of the following is true:

• The veteran was discharged or separated for medical reasons, early out, or hardship. • The veteran served in a theater of combat operations within the five years prior to applying for benefits. • The veteran was discharged because of a disability (not preexisting). • The veteran was a prisoner of war. • The veteran received a Purple Heart medal. • The veteran now receives VA Pension or disability benefits or state Medicaid benefits.

If a veteran doesn’t fall into one of the above categories, eligibility for medical benefits depends on the veteran’s current income and net worth. There’s a reduction in counted income for a veteran’s regular medical expenses. The specific dollar limits on income and assets depend on the number of the veteran’s dependents and where the veteran lives. The VA provides an online financial calculator to help veterans determine whether their income and assets make them eligible for veteran medical benefits. But that’s only an unofficial estimate, and a veteran won’t know for sure if he or she is eligible for benefits until actually filing an application.

What’s the priority group system for VA medical benefits?

Veterans who apply for VA medical benefits are placed in one of 8 priority groups. The VA uses this system to decide priority in receiving certain VA medical benefits that are limited by budget or space. A veteran’s assigned group might determine priority in scheduling medical care or a place in a VA long-term care facility. Also, veterans enrolled in Priority 7 and 8 must pay co-payments for many types of care (see below). And because of budget problems, the VA sometimes suspends accepting applicants in Priority 8. Currently they are accepting this group.

What VA medical benefits are available?

The basic medical care available to a veteran enrolled in the VA medical benefits program includes:

• Inpatient hospital care • Hospital emergency room services • Outpatient hospital, clinic, doctor, and chiropractic services • Mental health, reintegration and substance abuse care • Preventive care (physical examinations, immunizations, various disease screenings) • Medical supplies • Prescription (and some over-the-counter) medications, prescribed by a VA doctor, on the VA’s restricted list of covered drugs and dispensed at a VA facility pharmacy • Women’s Health services

Where can a veteran obtain VA medical care? Page 3 Except in rare circumstances, all VA medical care must be provided by a VA medical provider at a VA medical facility. Once a veteran is enrolled in the VA medical system, the veteran can obtain care at any VA medical facility, though not all facilities provide every type of care. If the facility where a veteran normally receives care cannot provide the specific care needed, the veteran may be referred to another VA medical facility. If the veteran requires specialized care that no nearby VA facility can provide, the VA may pay for the expense of the veteran traveling to a VA facility that can provide the care, or the VA may make a special arrangement to have the veteran treated by a non-VA provider. Once enrolled in the system, a veteran can find nearby VA medical facilities by going to the VA’s online facility locator. Then the veteran must make appointments directly with the facility where he or she is to receive care. Emergency medical care can be obtained at any VA medical facility. If an emergency requires treatment at a non-VA facility because no VA facility was reasonably available, the VA usually pays for that emergency care. If emergency services are obtained at a non-VA facility, a claim for reimbursement must be filed at the VA facility closest to where the emergency service was provided.

What’s the cost to a veteran for VA medical benefits?

Some veterans must make co-payments when they receive VA health care or medications. Which veterans must make a co-payment, and how much they must pay, depends on the priority group they’re assigned to and the type of medical service they receive.

Medication: Some veterans owe no co-payments for medications, including veterans with a 50 percent or higher service-connected disability rating, veterans receiving medication for service-connected conditions, and veterans whose annual income doesn’t exceed the maximum annual rate of the VA pension.

Inpatient care: Veterans in Priority Groups 1 through 6 have no co-payments for inpatient hospital care. Veterans in Priority Group 7 are responsible for paying $213.60 for the first 90 days of inpatient hospital care during any 365-day period. For each additional 90 days, the charge is $106.80. There’s also a $2 per day charge. Veterans in Priority Group 8 must pay $1,068 for the first 90 days of inpatient hospital care during any 365-day period. For each additional 90 days, the charge is $534. There’s also a $10 per day charge.

Outpatient care: Veterans in Priority Groups 1 through 6 have no co-payments for outpatient medical care.

For veterans in Priority Groups 7 and 8, there’s a three-tiered co-payment system for outpatient services: • A $15 co-payment for a primary care visit • A $50 co-payment for specialist care • No co-payment for many services, including preventive screening, immunizations, weight reduction, smoking cessation counseling (individual and group), laboratory testing, radiology (X-rays), electrocardiograms, and hospice care

Veterans who aren’t exempt from co-payments pay $8 for each 30-day (or less) supply of medication provided by the VA. For veterans enrolled in Priority Groups 2 through 6, there’s a maximum annual co-payment of $960 for medications. How are VA medical benefits and Medicare connected? Page 4 Many veterans enrolled in the VA medical system are also enrolled in Medicare. If so, the veteran may have a choice about which system covers a particular medical treatment or service. But the VA and Medicare won’t both pay for the same treatment -- it’s one or the other. If a veteran receives a medical treatment from the VA medical system, the VA pays for it. This can include a few health care services that Medicare doesn’t cover, or that the VA provides more extensive care for. Also, for many veterans there are no co- payments; when a veteran does have a co-payment, it’s often lower than Medicare’s. But a veteran enrolled in Medicare may prefer to receive some treatment outside the VA medical system and have Medicare cover it. If so, the VA will not pay any part of the bills that Medicare doesn’t pay (except for some emergency care).

Understand the Veterans Benefit Administration

As one of three administrations within Veteran Affairs, the Veterans Benefits Administration (VBA), in partnership with the Veterans Health Administration (VHA) and the National Cemetery Administration (NCA), provides benefits and services to service members, Veterans, and their families in recognition of their service to the nation.

To help you better understand the services VBA offers, the Oregon Department of Veteran Affairs (ODVA) provides a resource guide for Veterans, their dependents and survivors annually. This guide discusses benefits at both the federal and state level.

In addition to this resource is a VA Veterans Benefits Timetable information sheet that explains what resources are available for how long after a Service Member discharges from the military they can receive certain benefits.

Lastly, there is an online edition of the U.S. Department of Veteran Affairs Benefits for Veterans, Dependents and their Survivors.

Accessing the VBA for benefits that you may be entitled is best accomplished by contacting the county veteran service officer (CVSO) in your county to schedule an appointment.

Here is a list of the varied benefits a Veteran, Service Member, their dependents and surviving spouse or domestic partner can receive depending on age, type of discharge, service-connection, and income below. Before you begin this often long and complex process, you should do a couple things:

• Make sure you have a copy of your DD214. • Make sure you have the necessary documents and evidence to support your claim. • Never, ever assume the VA has the necessary information. • Respond to all VA requests for further information quickly and document your communications. • Make sure your claim number is on all correspondence and all documents.

OVERVIEW OF BENEFITS

Disbability Compensation Service-connected disability compensation is a tax-free benefit paid to Veterans for a Page 5 disability (or disabilities) that either: • Originated in service • Was worsened or aggravated by service • Is presumed by VA to be related to military service

Disability compensation may also be paid to Veterans disabled from VA health care. To receive disability compensation, you had to have been discharged under other than dishonorable conditions.

Veterans or Service Members with a disability that resulted from an injury or disease incurred or aggravated during active duty may be eligible for a grant to purchase a new or used automobile. They may also use a VA grant to adapt a vehicle so that they can drive or ride in it.

Pension Pension is a tax-free benefit paid to wartime Veterans with limited or no income who are either 65 or older or to Veterans younger than 65 who are permanently and totally disabled. Seriously disabled or housebound Veterans receiving pension may also qualify for an additional Aid and Attendance or Housebound benefit.

Education and training VA pays benefits to eligible Service Members and Veterans while they are pursuing an approved education or training program. There are four primary VA education benefit programs that cover active duty, National Guard and Reserve service members, and Veterans:

• Post-9/11 GI Bill » Montgomery GI Bill-Active Duty » Montgomery GI Bill-Selected Reserve » Reserve Educational Assistance Program (REAP)

The Post-9/11 GI Bill program provides financial assistance toward tuition and fees, books, supplies and a monthly housing allowance. VA pays a monthly allowance under the other benefit programs to help offset educational costs.

Home loans Veterans and active duty, National Guard and Reserve service members may be eligible for VA’s home loan program. VA loans have favorable terms, including no down payment or mortgage insurance premiums. VA borrowers have the added advantage of VA’s ability to step in and work with their loan servicer should mortgage payment difficulties arise.

VA offers a number of housing benefits and grants: • Guaranteed loans: VA can guarantee a portion of a loan made by a private lender to help buy a home, a manufactured home, a lot for a manufactured home or a condominium unit for their own personal occupancy. VA also guarantees loans for building, repairing and improving homes. • Re-financing loans: Whether you have a VA or non-VA mortgage, VA can help you re- finance your loan. • Specially-adapted housing grants: Certain severely disabled Veterans and military personnel can receive grants to adapt or acquire housing suitable for their needs. Page 6 Life Insurance VA provides important insurance benefits to Service Members and Veterans who may not be able to get insurance from private companies because of the extra risks involved in military service or because they have service-connected disabilities. • Service Members’ Group Life Insurance (SGLI): provides coverage for Service Members that expires shortly after discharge. It can be extended for a longer period if the Service Member is totally disabled. • Service Members’ Group Life Insurance Traumatic Injury Protection (TSGLI): is an automatic feature of SGLI that provides payments for Service Members who suffer losses, such as amputations, blindness and paraplegia, due to traumatic injuries. • Veterans’ Group Life Insurance (VGLI): allows Service Members to convert their SGLI to lifetime renewable term coverage after separation from service. • Service-Disabled Veterans’ Insurance (S-DVI): provides coverage for Veterans with a service-connected disability. If totally disabled, Veterans are eligible for additional coverage. • Veterans’ Mortgage Life Insurance (VMLI): provides mortgage life insurance to cover the home mortgages of disabled Service Members and Veterans who have received Specially Adapted Housing Grants from VA.

VA also offers a fiduciary program that protects the benefits paid to Veterans and other VA beneficiaries who are unable to manage their financial affairs. The fiduciary manages the beneficiary’s VA income and ensures that the beneficiary’s debts are paid.

Career preparation and independent living services: VA provides assistance to Veterans with service-connected disabilities to prepare for, obtain and maintain suitable employment through the Career Preparation and Independent Living Services’ Vet Success program. Vet Success provides vocational counseling, job search assistance and other education and training services, and it also offers career counseling to Veterans without disabilities. VA conducts a comprehensive evaluation to assist Service Members and Veterans to determine their future career paths. VA also offers comprehensive rehabilitation services to Veterans entitled for Vet Success services in order to help them obtain employment and to live as independently as possible.

Burial: VA offers certain benefits and services to honor our nation’s deceased Veterans.

• VA can furnish a monument to mark the grave of an eligible Veteran. • VA can provide a Presidential Memorial Certificate (PMC) for eligible next of kin and loved ones of honorably-discharged, deceased Veterans. VA can provide an American ﬂag to drape an eligible Veteran’s casket. • VA offers some reimbursement for funeral and burial expenses. • Qualifying Veterans and dependents can be buried in a VA national cemetery.

VA provides a bronze medallion that can be affixed to an existing privately purchased headstone or marker to signify the deceased’s status as a Veteran. The medallion can be furnished instead of a traditional Government headstone or marker for Veterans who died on or after Nov. 1, 1990, and whose grave is marked with a privately purchased headstone or marker in a private cemetery.

Page 7 Dependents and survivors: VA’s benefits for dependents and survivors are generally available to an unmarried surviving spouse and dependent children of:

• Service Members who died during active military service. » Veterans who died from a service-related disability after serving. • Certain Veterans with a completely disabling service-connected disability

VA’s benefits for dependents and survivors include: • Dependency and Indemnity Compensation (DIC): a monthly benefit available to eligible parents, spouses and dependent children. • Survivors’ Pension—a monthly benefit to surviving spouses and children of Veterans who died from a non-service connected cause and meet income and net worth limitations. • The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)— a comprehensive health care program in which the VA shares the cost of covered health care services and supplies. • The Survivors’ and Dependents’ Educational Assistance (DEA) Program (Chapter 35)— provides education and training benefits. • Home Loans— an unmarried surviving spouse of a Veteran who died on active duty or as the result of a service-connected disability is eligible for VA’s home loan benefit. The loan may be used to purchase, construct or improve a home or to re-finance a mortgage.

Health care: VA provides a number of health care services, including:

• Hospital, outpatient medical, dental (if service connected), pharmacy and prosthetic services • Domiciliary, nursing home and community-based residential care • Treatment related to Military Sexual Trauma (MST) » Readjustment counseling » Health and rehabilitation programs for homeless Veterans • Alcohol and drug dependency treatment • Medical evaluation for disorders related to Gulf War service or environmental hazards • Specialized health care for women Veterans

Caregiver options: Caregivers provide personal care services to Veterans who are seriously injured, chronically ill, disabled or are getting older and are no longer able to adequately care for themselves. VA offers assistance and support to caregivers through services such as Respite Care, Adult Day Health Care (ADHC) Centers, Home-Based Primary Care, Home Tele-health, and home equipment and modification. VA offers comprehensive training, counseling, a stipend and health insurance coverage to Family Caregivers of Veterans who incurred or aggravated a serious injury in the line of duty on or after 9/11.

While this is a brief and general overview of the benefits Veterans, Service Members, and their dependents can receive, there are also state-specific benefits in addition to the federal above that may be applicable. Please look at the state list to see what the criterion is before you meet with a CSVO of your county.

Page 8 Characteristics of veterans and active military Those who serve in the military typically: • Have amazing drive and initiative. • Show a fearlessness in facing obstacles. • Are mission- and task-oriented. • Are doers and fixers. • Exhibit leadership qualities and can typically prioritize effectively for the good of the whole. • Have a team mentality -- the unit is everything, and one’s job is to support them and the mission. • Value and exemplify dependability, accountability, steadfast bearing/conduct, courage, decisiveness, endurance, enthusiasm, integrity, selfessness and loyalty. • Have immense resilience.

Those who interact with this population can draw upon some universal military-related strengths/skills.

At a basic level, most veterans have these abilities: • Can complete strenuous physical tests. • Can disassemble and reassemble multiple technology quickly. • Can read maps and detailed manuals. • Value working in a team. • Can follow complex directions and assignments quickly.

One could easily equate serving in the military to going to vocational technology college. Many positions in the military are difficult or unavailable to translate to the civilian sector. Joining Forces, a program headed by Dr. Jill Biden and First Lady Michelle Obama, is working with state governors to establish credentials and licensing for those discharging to the civilian sector.

Assumptions and actions to be avoided: Be aware of pathologizing thinking when it comes to those who have served. • Not all are the same. • Not all are “broken.” • Not all are “soldiers”: • Marines are called Marines. • Navy personnel are called seamen. • Air Force personnel are called airmen. • Army personnel are called soldiers. • Being in the Navy does not equate to “being on a boat.” • Each branch has its own specific ranking system (this is easily googled). • Women are included in the terms despite root word containing “men.”

When you talk with the veteran or active duty

• Do not fake interest, knowledge, and/or experience with this population. They will know. • Do not say you understand how they feel. Page 9 • Do not assume war was horrible for them. • Do not assume all require mental health treatment. • Be direct. No “B.S.” Those who have served will know the difference between faking the talk and walking the walk. • Above all, respecting and validating someone’s experience is universal. This skill applies here with veterans and military personnel especially. • Be dependable. Accountability is a very important trait taught and reinforced in the military. • Be curious. A genuine, respectful and authentic curiosity about someone’s service will translate to being interested and willing to learn about the person’s experience.

Military culture and conditioning The military has a simple function: to defend and protect our nation against enemies foreign and domestic. A new recruit swears an oath to do this. They agree to be sent wherever, whenever, for however long the particular mission requires. The mission comes first, always. The new recruit begins basic training, where conditioning begins.

There is no space for “weakness.” One must carry their weight and support the mission at all costs. Often times a stigma will follow those who do not complete their duties effectively. Individualism is suppressed, and a team mentality is enforced. This is not a bad trait; this kind of strength is needed to compartmentalize the tasks and actions expected of the recruit during their service.

The military works on a clear form of reward and punishment. Those serving are told what to do, and they do it. Service members are expected to be disciplined in their actions and words and to maintain control of their emotions and their physical selves at all times.

Along with discipline and control comes focus. Focus is important to mission success, and the military branches teach young recruits how to focus in challenging situations—situations where they are lacking sleep, are physically exhausted, or are under unaccustomed and extreme stress.

A service member who may have either physical or emotional stress may keep this to themselves until they can no longer manage it, due to (for instance): infrastructure of their family fracturing as a result; employment is in jeopardy or lost; they simply cannot function. For veterans, being conditioned to feel that asking for help is a sign of weakness becomes a hindrance that can be disruptive in the civilian world. As a result, it’s common that veterans experience multiple needs, such as PTSD and substance abuse at the same time (co-morbidity and dual diagnosis are examples of words that are associated with multiple needs and diagnoses).

The VA, the military branches and the civilian world have all recognized this cognitive dissonance, but they are still far from a solution. Enrollment in the VA can be beneficial and should be emphasized to those veterans who have not, because it’s helpful for decision-makers to comprehend the extent of need for specialized care. Please understand the complex intersectionality of service members, active or veteran. There are many hierarchies within the military and tremendous variety in experiences. This, compounded with the social, economic, racial, and other categories that occur in one’s life, can create a very unique and complicated situation. Please be patient, be open and be respectful. Page 10 What can you do to learn more?

Reach out to a veteran you know. Chances are you have one in your friendship circle or family. Ask them about their experience. Practice engaging with the population by engaging those you love. It is a win-win! Do not ask inappropriate questions such as if they have killed or what that was like if they did. Ask what their experience was like. Hear their story. Veterans have an amazing story to tell.

Talk with your military liaison about questions and ideas you may have. Ask for more information.

Your Military Liaison has a resource book of peer-reviewed articles about this complex population.

Go to the ODVA website http://www.oregon.gov/odva and educate yourself on what benefits are out there.

Additional resources: http://maketheconnection.net/ -stories and narratives of veterans. http://www.mentalhealth.va.gov/ - mental health services and information for military and veterans. http://www.socialworkers.org/military.asp -NASW social work guide to helping military and veterans. http://www.veteransunited.com/network/ - general resource for veterans and their families. http://www.oregonmilitarysupportnetwork.org/ -mutual support and service coalition for military. http://www.operationhomefront.net/ a mutual aid/support organization for veterans and military.

Sources

• Oregon Department of Veteran Affairs Statistics Page: http://www.oregon.gov/odva/info/ Pages/stats.aspx • SAMSHA: Understanding the Military: The Institution, the Culture, and the People. http://partnersforrecovery.samhsa.gov/docs/military_white_paper_final.pdf • Military Culture: From Combat to Coming Home, a Social Worker’s Primer. Oregon De- partment of Veteran Affairs presentation, February 13, 2013, Portland State School of Social Work. • Summary of VA Benefits. Washington D.C.: U.S. Department of Veteran Affairs, 2012. PDF. • Krokus, Rachel. Veteran Resource Guide for Social Workers. N.d. Informal guide to working with Veterans. OIF/OEF/OND Program, Portland VAMC, Portland, Oregon. PDF. • Black, Eddie, SSGT. Military Culture- A Primer. Portland, Oregon: Military Wives Matter, OHSU, 15 Sept. 2011. PDF. Page 11 Learn more at: www.211info.org