Veterans Administration (VA) LTSS

Post-traumatic Stress Disorder (PTSD) is, “a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident or sexual assault”.6 Native veterans may have higher rates of PTSD than white veterans. PTSD resulting from combat situations is compounded by a high rate of PTSD among the AI/AN general population.

The contributing factors to PTSD among the general AI/AN population are complex and include historical trauma and high rates of interpersonal violence. Although PTSD does not always result in a loss of ability to live independently and perform activities of daily living, PTSD can severely impact an individual’s ability to function, particularly in elderly individuals. A 2010 study funded by the U.S. Department of Defense found that male veterans ages 55 years and older with a PTSD diagnosis were more than twice as likely to develop dementia than male veterans of the same age group without a PTSD diagnosis. Based on this data and the increasing elderly population, the LTSS needs related to dementia are likely to increase among Native veterans.

Native veterans experience several barriers to LTSS services. These barriers result from Native veterans’ poor access to care and complications from accessing care through Indian Health Service (IHS) and VA.

Several studies report that Native veterans are more likely to lack health insurance than other groups of veterans. In addition, Native veterans are more likely to delay care than White veterans due to their inability to obtain timely appointments and lack of transportation to health care facilities.  Native veterans are also more likely to live in highly rural areas than non-Native veterans. Within these rural areas, Native veterans must travel significant distances to receive any health care services, including LTSS services, yet they lack reliable transportation options.

Several studies report that Native veterans are more likely to use Indian Health Service (IHS) than VA for their health care needs. Native veterans appear to utilize IHS more frequently than VA due to several practical, geographical, and cultural reasons. While many of IHS’ facilities and programs are underfunded, IHS employs culturally specific care. TIHS cultural awareness and sensitivity makes IHS a more attractive option than VA for Native veterans. Native veterans may also distrust or become frustrated with VA, adding to their preference for IHS. Further, Native veterans living in rural communities have limited or no access to VA Medical Centers. These barriers to VA care are problematic, as VA is better equipped to provide LTSS services to Native veterans than IHS.  Despite a preference for IHS, Native veterans do utilize VA. One study found Native veterans more likely to report use of VA health care services than veterans of all other races.

Overall, the literature conveys a lack of coordination between IHS and VA to provide quality care, including LTSS services, to Native veterans. Although there are Native veterans who use IHS and VA, the providers do not routinely share medical information with each other. Improved coordination between IHS and VA is critical, as dual use of IHS and VA may be the best approach to handle the complex health and LTSS needs of Native veterans.

IHS and VA are working to improve their coordination of care, availability of services, and understanding of each other’s abilities and limitations to better serve Native veterans. Coordination and educational efforts are detailed in the IHS-VA Memorandum of Understanding (MOU), while improved access to VA services is a highlight of the Veterans Access, Choice and Accountability Act (Choice Act). VA is also developing some promising LTSS practices that may improve Native veterans’ access to care.

IHS and VA acknowledge the need to improve their coordination and have taken several steps to address their shortcomings. In 2003, IHS and VA signed an MOU to improve their coordination of care for Native veterans. The MOU was updated in 2010 to further address the need to coordinate LTSS implementation for Native veterans, particularly as VA already provides LTSS.

The Choice Act was signed into law in 2014. The Choice Act aims to improve veteran access, including Native veterans, to health care by allowing veterans to “receive care from eligible non-VA health care entities or providers.”  The law further states that “Eligible non-VA entities or providers must enter into agreements with VA to furnish care.”  TIHS language initially caused concern in Indian Country, as IHS is not part of VA. However, in a tribal consultation letter, VA clarified that IHS and tribal health programs “will remain members of [VA’s] core providers network”. The Choice Act seeks to strengthen VA’s relationship with IHS and further their partnership, which could lead to improved access to care for Native veterans.

The Alaska Native Tribal Health Programs (ATHP) exemplifies the strengthened partnership between VA and IHS. In 2012, ATHP entered into an agreement with VA that enabled VA to pay IHS and tribal facilities for health care services provided to Alaska Native veterans. TIHS agreement led to increased access to health care services for Alaska Native veterans in Alaska. Given the remote nature of many communities in Alaska, this increased access to care is especially promising. Further innovative collaboration between IHS and VA has the potential to improve access to LTSS for Native veterans throughout Indian Country.

HBPC provides primary care in the home to elderly, frail, or chronically ill veterans who are homebound and would otherwise have to receive care in an institution. AI/AN communities have an overall cultural preference to provide care for family members in their own homes and communities, rather than in formal institutions, which makes the HPBC program particularly appealing. Fourteen VA medical centers have expanded access to HBPC through collaborations with IHS or tribal programs. The HPBC program’s holistic approach and focus on case management appears to lend itself to a high level of cultural sensitivity and respect for Native veterans. Furthermore, HPBC programs engage in proactive outreach to tribal communities and are generally well received by those communities.

VA also has a Medical Foster Home (MFH) program, which is now nation-wide and is a viable, community-based alternative to VA nursing homes. The MFH program allows veterans with physical and mental disabilities to reside in their communities by pairing veterans with trained caregivers who share their homes with the veterans. The MFH program is intended for veterans with no available family caregiver and VA inspects and approves all MFH facilities. A study of the program found that MFH residents experience fewer hospitalizations due to mental health problems and bacterial infections than those in VA nursing homes, which alludes to a higher quality of care and a higher quality of life for MFH residents. Although the effectiveness of the MFH program has not yet been evaluated among Native veterans, it is a promising model that should be explored.

“A Veteran is a person who served in the active military, naval or air service and who was discharged or released under conditions other than dishonorable.