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CE: Original Research Primary Care Providers and Screening for Military Service and PTSD

Mohler, Kristin Michelle MSN, BSN, RN, FNP-C; Sankey-Deemer, Cydnee MSN, BSN, RN, FNP-C

AJN The American Journal of Nursing: November 2017 - Volume 117 - Issue 11 - p 22–28
doi: 10.1097/01.NAJ.0000526720.34516.4b
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Background: Most veterans have the option of receiving their health care from the Veterans Health Administration or through primary care providers in the private sector. However, there is some evidence that fewer than half of community-based, private sector primary care and mental health providers screen their patients for military service, particularly in rural areas, leaving these veterans less likely to be screened for posttraumatic stress disorder (PTSD) and other military service–related conditions.

Purpose: To determine whether primary care providers in the private sector are screening patients for military service and subsequent PTSD.

Methods: We designed and piloted a survey to determine whether primary care providers in a rural Pennsylvania region routinely screen for military service and service-related PTSD. We distributed the survey to a convenience sample of more than 250 primary care providers in central and western Pennsylvania through the U.S. Postal Service, via Facebook, and via work e-mails for those who worked in a local health system.

Results: Among 50 eligible respondents, only four (8%) said they screen all their patients for military service, and 20 (40%) reported screening none; only two respondents (4%) screened all their patients who have served in the military for PTSD, and 30 (60%) screened none.

Conclusion: Veterans who rely on private sector providers may not receive evidence-based care for military service–related health problems, including PTSD. To improve care for these patients, providers in the private sector should be educated on why all patients should be screened for military service, how to conduct such screening properly, and veterans’ general health concerns.

Evidence shows that veterans who receive their health care from private sector providers are less likely to be screened for military service–and therefore may not be treated for service-related health conditions. Here, the authors explore whether rural Pennsylvania providers offer this screening to their patients.

Kristin Michelle Mohler is a nurse in the critical care department at Butler Memorial Hospital in Butler, PA. Cydnee Sankey-Deemer is a family NP at Penn Highlands Healthcare, Philipsburg, PA. Contact author: Kristin Michelle Mohler, k.m.mohler@outlook.com. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

In 2014 the U.S. Department of Veterans Affairs (VA) was rocked by reports of veterans dying while waiting for care at Veterans Health Administration (VHA) facilities, which led to calls for increasing the involvement of private sector providers in veterans’ care. Congress passed and President Barack Obama signed into law the Veterans Access, Choice, and Accountability Act, which included temporary funding for the Veterans Choice Program (VCP), allowing veterans to receive care from non-VHA providers at the government's expense.1 Many more veterans than expected made use of the VCP, and it was due to run out of money this past August. However, at the end of July, the Congress passed a $2.1-billion spending bill to continue funding the program, and on August 12, President Donald Trump signed the bill into law.2

According to the VA, any person who has served on active duty and was not dishonorably discharged may be eligible for free health care benefits.3 Veterans are required to apply for enrollment to determine their coverage. The VA's health benefits are administered by the VHA according to an enrollment system based on eight priority groups (see the health benefits section of the VA website: www.va.gov/healthbenefits/resources/priority_groups.asp). Many veterans don't apply for enrollment and obtain private health care coverage through their employer or spouse. Other veterans may qualify for free services but seek care in the private sector because there are no VHA facilities nearby or the waiting list for appointments is too long.

President Trump has been outspoken about his interest in increasing privatization of health care for veterans, but will the private sector be able to address veterans’ special health needs? A 2011 survey of 319 private sector primary care and community-based mental health providers conducted by Kilpatrick and colleagues showed that only 44% reported screening their patients for military service; even fewer (37%) of those working in rural areas did so.4 These findings indicate that veterans receiving health care in the private sector are less likely to be screened for posttraumatic stress disorder (PTSD) and other military service–related conditions than those who receive their care through the VA. As RNs working in a rural area of Pennsylvania, we wanted to determine whether non-VA primary care providers in central and western Pennsylvania screen their patients for prior military service and subsequent PTSD.

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BACKGROUND

After serving in the military, veterans may be at risk for long-term health problems and often have disabilities that affect their return to civilian life. According to the National Council on Disability, approximately 25% to 40% of veterans are affected by disabilities that are not easily recognized.5 This includes PTSD as a result of witnessing or being involved in a traumatic event, receiving a traumatic brain injury, or experiencing sexual trauma.

While studies have shown that veterans of the wars in Iraq and Afghanistan have rates of PTSD ranging from 11% to 20%, and the rate among Vietnam veterans is as high as 30%, the VA reports that only 8% of the 5 million veterans using VHA care have received this diagnosis.6, 7

If veterans with PTSD are not diagnosed and treated, they can suffer from a variety of health impairments and functional difficulties. Maintaining healthy social relationships, focusing on work, and functioning in environments that may trigger unpleasant memories of their war experience can become a daily struggle.5 They are also more likely to develop heart disease than those who don't have PTSD.8

PTSD is also linked to suicide, and the suicide rate among veterans has been rising over the past 10 years. The VA found that in 2014 the rate of suicide was 35.3 per 100,000 veterans.9 According to Price and Stevens, the marriages of veterans diagnosed with PTSD are twice as likely to end in divorce as those of veterans without the diagnosis.10 Likewise, family members who care for veterans with PTSD shoulder a greater burden, including physical, emotional, and financial strains.10

Services and access to care. According to the U.S. Census Bureau, in 2014 there were approximately 19.3 million veterans in the United States.11 While approximately 9.1 million veterans were enrolled in the VHA's health program, others who were eligible weren't enrolled.12 Undoubtedly, this is still the case. Still others may be enrolled but continue to use the private sector for care. To qualify for the VCP, a veteran must have at least a 30-day wait for VHA medical care or live more than 40 miles from a VHA medical facility.13

Nayar and colleagues found that distance has been the main barrier to receiving care at a VHA facility and that many veterans have already established a relationship with a non-VHA provider, preferring to receive care in the private sector.14 According to the American Legion, about 30% of veterans who served in Iraq and Afghanistan since 2001 live in rural areas.15 The VHA has attempted to improve health care access for these veterans by developing the VHA Office of Rural Health.15

Box.

Box.

While there has been a growing concern about the quality of care that the VHA health system provides to veterans, resulting in increased scrutiny, the care that veterans receive in the private sector has not garnered the same level of attention. In the 2011 survey by Kilpatrick and colleagues in which the majority of primary care providers and community-based mental health providers reported not screening their patients for military service, most also said they were unfamiliar with the best practices for treating PTSD and traumatic brain injury associated with military service.4 In 2013 the American Academy of Nursing (AAN) developed an initiative called “Have You Ever Served in the Military?” with the intention of raising awareness among veterans and private sector health professionals of the importance of screening for military service and PTSD.16 (See Have You Ever Served in the Military?17)

The purpose of our study was to ascertain whether primary care providers in the private sector were screening patients for prior military service and subsequent PTSD. Specifically, we designed and piloted a survey that asked the questions, “How many of your patients do you currently screen for military service?” and “Out of your patients who have served in the military, how many do you screen for PTSD?”

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METHODS

Ours was a quantitative, cross-sectional, nonexperimental study consisting of an online survey. The study was determined to be exempt from the rules governing research on human subjects by the institutional review board at Pennsylvania's Edinboro University, where we were in school at the time.

Sample. The sample consisted of primary care providers in central and western Pennsylvania. We defined primary care providers as physicians, NPs, and physician assistants who practice in primary care. Potential participants were identified using online search engines, professional connections, and provider directories linked to insurance companies. We mailed information about the study and an invitation to participate in the survey to 250 primary care practices in central and western Pennsylvania. We included a link for providers to access the survey. We also used Facebook to distribute the information and link to the survey. A local health care system also distributed the survey information to their affiliated primary care providers via their e-mail directory. A total of 58 primary care providers responded. Because the letters were sent to providers’ offices, not individuals, and Facebook posts can be seen by many, we don't know how many primary care providers we reached, so we were unable to calculate a response rate.

Box.

Box.

Survey. We designed a survey consisting of 10 closed-ended questions (see Survey Questions). The survey included questions on participant demographics, previous military experience, friends or family who have served, awareness of the AAN's “Have You Ever Served in the Military?” initiative, any prior education on providing health care to veterans, and the volume of patients currently screened for military service and PTSD.

We conducted a pilot study with eight providers to ensure face and content validity. The respondents included four physicians, three physician assistants, and one NP. Those who completed the survey felt that it was easy to read and the questions were clearly presented. There were no recommendations for changing any questions; however, they did ask if information would be provided along with the survey to educate participants on screening for military service and PTSD. As a result, we added information on the AAN's initiative to the end of the survey. All data were analyzed using descriptive statistics.

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RESULTS

A total of 58 primary care providers agreed to participate in the survey; however, eight did not answer any of the survey questions and were excluded. Five respondents wrote “U.S.” as their county of practice, which was likely because they misread “county” as “country.” Because the participants’ consent specifically stated that the survey was for primary care providers in central and western Pennsylvania, we did not feel it necessary to exclude those responses. A total of 50 eligible responses were included in data analysis.

Table 1

Table 1

“In what county do you practice?” was considered a demographic question to limit the research to the specific area of central and western Pennsylvania. Most respondents were located in Butler County (62%, n = 31). Physician assistants constituted the largest proportion of respondents (38%, n = 18); because two participants did not respond to this question, the total number of respondents was 48. See Table 1 for information on the providers who participated in the survey.

Forty-eight percent (n = 24) of respondents were male and 52% (n = 26) were female; they ranged in age from 25 to 65 years, with a mean age of 42 years. The overwhelming majority (96%, n = 48) had never served in the military in any capacity, but most (78%, n = 39) had close friends or family who had. Only 8% (n = 4) of providers were familiar with the AAN's “Have You Ever Served in the Military?” initiative; this included only one of the 11 NPs who completed the survey.

A total of 12% (n = 6) of respondents had previous training in providing health care to patients who had served in the military, and four of those reported that they screened few or none of their patients for military service or PTSD. The remaining two both answered that they screened most patients for military service; one screened most patients for PTSD, and the other screened few patients for PTSD.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

In answer to the question “How many of your patients do you currently screen for military service?” only 8% (n = 4) responded that they screen all of their patients, while 40% (n = 20) said they screened none (see Figure 1 for the full distribution). And in response to the question “Out of your patients who have served in the military, how many do you screen for PTSD?” 60% (n = 30) of respondents said they screened none of these patients for PTSD and only 4% (n = 2) said they screened all of them (see Figure 2).

The participants who were familiar with the AAN initiative screened all or most of their patients for military service and PTSD.

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DISCUSSION

Popular films such as American Sniper and media attention have raised public awareness of PTSD, traumatic brain injury, and veteran suicides to some degree, but the question remains: are health care providers identifying the veterans among their patients and subsequently screening them for PTSD? We found that the primary care providers in rural central and western Pennsylvania who practice outside of the VHA health system are unlikely to routinely screen all patients for prior military service and known veterans for PTSD. Among the providers who participated in this study, 60% did not screen known veterans for PTSD. However, those who knew about the AAN's “Have Your Ever Served in the Military?” initiative screened most or all of their patients for military service and PTSD. Only two of the 50 respondents had served in the military themselves; one screened most patients known to be veterans for PTSD and the other screened a few veterans for PTSD.

This study is limited by its reliance on a convenience sample in central and western Pennsylvania, which means the results cannot be generalized to all primary care providers within the United States. In addition, because we do not know how many primary care providers saw the request to participate in the study, we were unable to determine a response rate. This could create a source of error if those who responded were the primary care providers who did not screen for military service and PTSD. Nonetheless, the study provides additional evidence that veterans who rely on private sector providers may not receive evidence-based care for military service–related health problems, including PTSD.

Future research should evaluate how providers who do not screen for military service have directly affected the health of veterans. Furthermore, a major effort will be needed to educate non-VHA health professionals about the special health problems that veterans may develop and how to treat them (see Continuing Education Opportunities).

Implications for practice. Findings from this study support other evidence that primary care providers do not screen their patients for military service and subsequent PTSD. If patients with PTSD go undiagnosed, this can cause physical illness and greater emotional suffering. When diagnosis and treatment of PTSD is delayed, this can lead to an increased risk of suicide attempts or completion. Primary care providers are on the front lines in the early identification and treatment of veterans’ physical and mental health concerns. It is the provider's responsibility to take action and improve screening practices.

There are many ways that nurses, primary care providers, and all health care providers can increase the number of patients being screened. The most important is to educate private sector providers, particularly those in primary care. Education should include the reasons why every patient needs to be screened, proper screening methods, general health concerns for anyone who has served in the military, and the AAN's “Have Your Ever Served in the Military?” initiative.

Office staff members can ask patients whether they've served in the military when they schedule an appointment and can assist providers by flagging the chart prior to the appointment; therefore, educating office staff could potentially increase the number of patients providers screen. They can also assist in supplying veterans with available resources, making arrangements for follow-up care, and if necessary, referrals to other providers.

Screening for and treating PTSD in veterans presents an additional challenge. Spoont and colleagues conducted a systematic review of tools used in primary care practices to screen for PTSD and found there is greater harm in failing to diagnose PTSD, and therefore delaying treatment, than there is in misdiagnosing PTSD.18 Our study also found that 40% (n = 20) of respondents did not screen any of their patients for military status, supporting the findings of Kilpatrick and colleagues, who reported that 47% of primary care and mental health providers did not screen their patients for military service.4

Lastly, further research is recommended to assess why so many providers don't screen any of their patients for military status or PTSD. Is it because they aren't familiar with the questions to ask once they identify the patient as a veteran? Do they know what tools to use when screening for PTSD in veterans? Do they feel comfortable discussing mental illness with patients or avoid it unless the patient discusses it first? These are questions that need to be answered to provide evidence-based practices for primary care providers or other health care professionals.

Implications for policy. Veterans can receive their health care services through the VHA or the private sector, or they can be comanaged by both. Nayar and colleagues reported that the main reasons veterans seek care from non-VHA providers or are comanaged are because they've already established relationships with non-VHA providers and are located too far from a VHA facility.14 Another issue in comanaged care is that the VHA uses an electronic health record (EHR) system that non-VHA providers cannot access. When private sector providers can't get the patient's past or current health care information, including assessments, diagnoses, medication lists, progress notes, and test results, care transitions are compromised. According to Gaglioti and colleagues, nearly three-quarters of primary care providers in the private sector found the VHA's communication to be poor (31%) or nonexistent (42%).19 The providers felt that it was difficult to obtain records from the VHA (which can result in duplicate or insufficient testing) and to talk with VHA providers directly (which can result in delay in care). If a veteran receives care only in the private sector and isn't screened for military service, the provider might be missing or misdiagnosing major health conditions.

Clearly, veterans would benefit from investment in an information infrastructure that would enable the VHA system and private practitioners to communicate. We should also expand efforts to require that EHRs in the private sector have the capacity to record whether patients are veterans or have family members who are veterans. Former VA assistant secretary for policy and planning Linda Schwartz, PhD, RN, FAAN, a veteran and former commissioner of veterans affairs in Connecticut, was instrumental in securing legislation that requires hospitals in the state to ascertain whether a patient is a veteran.20 Other states should consider doing the same, but health care facilities and providers should be routinely assessing patients for prior military service without state mandates. Screening should be considered a “best practice.”

Funding is also needed to enable the VHA to mount a significant educational effort for health professionals in the private sector to ensure that they are knowledgeable about screening for military service and its health sequelae.

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Continuing Education Opportunities

Military Culture Training for Community Providers

www.va.gov/opa/choiceact/documents/FactSheets/Military_Culture_Training_Fact_Sheet_FC_0415_1.pdf

PTSD: National Center for PTSD

Continuing Education

www.ptsd.va.gov/professional/continuing_ed/continuing_education_credit.asp#NON-VA

PTSD Consultation Program for Providers Who Treat Veterans

www.ptsd.va.gov/professional/consult/index.asp

PTSD Screening and Referral: For Health Care Providers

www.ptsd.va.gov/professional/provider-type/doctors/screening-and-referral.asp

PTSD = posttraumatic stress disorder.

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REFERENCES

1. U.S. Department of Veterans Affairs. Veterans Access, Choice and Accountability Act of 2014 (“Choice Act”). Washington, DC; 2014. Fact sheet; https://www.va.gov/opa/choiceact/documents/choice-act-summary.pdf.
2. U.S. Department of Veterans Affairs. About the choice program. 2017. https://www.va.gov/opa/choiceact/index.asp.
3. U.S. Department of Veterans Affairs. Health benefits: veterans eligibility. n.d. https://www.va.gov/healthbenefits/apply/veterans.asp.
4. Kilpatrick DG, et al Serving those who have served: educational needs of health care providers working with military members, veterans, and their families. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research and Treatment Center; 2011 Dec 1.
5. National Council on Disability. Invisible wounds: serving service members and veterans with PTSD and TBI. Washington, DC; 2009 Mar 4. http://www.ncd.gov/rawmedia_repository/veterans.pdf.
6. U.S. Department of Veterans Affairs, Office of Research and Development. Study explores reasons why veterans seek—or don't seek—PTSD care [news release]. 2014 Apr 24. https://www.research.va.gov/currents/spring2014/spring2014-25.cfm.
7. U.S. Department of Veterans Affairs. How common is PTSD? n.d. https://www.ptsd.va.gov/public/ptsd-overview/basics/how-common-is-ptsd.asp.
8. Sidney S Post-traumatic stress disorder and coronary heart disease J Am Coll Cardiol 2013 62 11 979–80
9. U.S. Department of Veterans Affairs. VA suicide prevention program: facts about veteran suicide. Washington, DC; 2016 Jul. https://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf.
10. Price JL, Stevens SP Partners of veterans with PTSD: research findings. Washington, DC: U.S. Department of Veterans Affairs, National Center for PTSD; 2017 Mar 30. https://www.ptsd.va.gov/professional/treatment/family/partners_of_vets_research_findings.asp.
11. U.S. Census Bureau. Veterans Day 2015: Nov. 11. Washington, DC; 2015 Nov 4. CB15-FF.23. Profile America facts for features; https://www.census.gov/newsroom/facts-for-features/2015/cb15-ff23.html.
12. Bagalman E The number of veterans that use VA health care services: a fact sheet. Washington, DC: Congressional Research Service; 2014 Jun 3. R43579. https://fas.org/sgp/crs/misc/R43579.pdf.
13. Commission on Care. Final report of the Commission on Care. Washington, DC; 2016 Jun 30. https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf.
14. Nayar P, et al Rural veterans’ perspectives of dual care J Community Health 2013 38 1 70–7
16. American Academy of Nursing. Have you ever served in the military? A service for America's veterans by the American Academy of Nursing. n.d. http://www.haveyoueverserved.com.
17. Collins E, et al “Have you ever served in the military?” Campaign in partnership with the Joining Forces initiative Nurs Outlook 2013 61 5 375–6
18. Spoont MR, et al Screening for post-traumatic stress disorder (PTSD) in primary care: a systematic review. Washington, DC: U.S. Department of Veterans Affairs, Health Services Research and Development; 2013 Jan. https://www.hsrd.research.va.gov/publications/esp/ptsd-screening.pdf.
19. Gaglioti A, et al Non-VA primary care providers’ perspectives on comanagement for rural veterans Mil Med 2014 179 11 1236–43
20. State of Connecticut Senate and House of Representatives. An act concerning the admission of veterans to hospitals and the application of military occupational training to state licensure requirements. Hartford, CT 2014.

For 12 additional continuing nursing education activities on topics related to the military, go to www.nursingcenter.com/ce.

Keywords:

mental health; military service; posttraumatic stress disorder; primary care providers; screening; veterans

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