Introduction
Telemental Health Services
Resources and References
Tribal Veterans Representative (TVR) Program

Introduction

One of the three core focus areas of the Native Domain is Programs. A variety of projects were developed to support implementation, identification and dissemination of information on culturally-competent best practices for rural Native (American Indian/Alaska Native/Native Hawaiian/Pacific Islander) Veteran clinical care and outreach. These programs include the Telemental Health Clinics and the Native Veteran Services directory of programs and services available to Native Veterans. Some of the reasons why rural Veterans are not receiving adequate health care and treatment are due to lower salaries for providers making recruitment and retention difficult, geographic barriers, complex clinical presentations, and limited resources. To address these concerns, the use of telehealth technologies in rural locations is rapidly increasing. Telehealth for mental health care or telemental health services are delivered in a variety of ways, including videoconferencing and telehome care. 

Telemental Health Clinics

The Telemental Health Clinics for Native Veterans with Post Traumatic Stress Disorder (PTSD)  were implemented due to an increasing amount of evidence showing that American Indian Veterans have the highest rate of PTSD of any ethnic group and face significant barriers to care. One of the biggest barriers is geography, ie living on reservations in rural and remote areas at great distances from medical facilities. The clinics provide ongoing mental health care including medication management; case management; and individual, group and family psychotherapy to Northern Plains Veterans living on or near rural American Indian reservations in Montana, Wyoming and South Dakota. This unique service within the VA system demonstrates an innovative model to provide greatly needed mental health services to an underserved rural minority. The general model and processes of care represented by these clinics hold promises of improved care and treatment for rural Veterans in general, as well as other underserved rural populations. Studies suggest that telemental health is as effective as face-to-face services and patient attitudes towards this delivery mechanism are positive.

The American Indian Telemental Health video (Length 19:58) presents an overview of a series of Telemental Health Clinics that use videoconferencing to provide remote mental health treatment to Native Veterans living on or near rural reservations in the Northern Plains. This population has unique health care needs and face numerous barriers to accessing health care services. These clinics provide a way to reach this vulnerable population and increase access to culturally specific care through collaborative efforts and partnerships.

Native Veteran Services

The Native Veteran Services directory is instrumental in providing up-to-date and accurate information on traditional healing programs and services available to Native Veterans. Due to the unique needs of Native Veterans, providing access to traditional healing services and activities recognizes this need and allows the VHA to increase healthcare and treatment opportunities through available resources.

Through the projects described here, we assess the potential of innovative disease management systems to improve access to services for rural Native Veteran populations.  These projects represent opportunities to engage in the process of adapting and testing interventions for rural Veterans and provide valuable frameworks for future clinical trials.  The telemental health program holds promise for reducing disparities in rural areas and for enhancing services for traumatized patients, primarily those with PTSD. The directory provides VA staff and Veterans with information and access to traditional healing services and programs as alternative resources to complement healthcare treatment.

Telemental Health Services

Telehealth Clinics: The University of Colorado Denver Centers for American Indian and Alaska Native Health (CAIANH) Connection

The mission of the Centers for American Indian and Alaska Native Health (CAIANH) is to promote the health and well-being of American Indians and Alaska Natives, of all ages, by pursuing research, training, continuing education, technical assistance, and information dissemination within a biopsychosocial framework that recognizes the unique cultural contexts of this special population.

The American Indian Telepsychiatry Clinics were initially established in April 2002 with a pilot telepsychiatry program from the University of Colorado Denver Centers for American Indian and Alaska Native Health (CAIANH)/VISNs 19 & 23 and an American Indian reservation in the Western United States. 

The clinic was established to improve the mental health care of rural American Indian Veterans via telepsychiatry services in the community in which these Veterans lived. Since then these clinics have expanded to multiple sites serving tribes in South Dakota, Montana and Wyoming. The clinics follow a shared model of a VA-credentialed psychiatric practitioner located at the CAIANH in Denver providing telepsychiatry services to a patient-site based on or near a rural American Indian reservation. The reservation clinic site is run administratively by a Tribal/Telehealth Outreach Worker (TOW) who also performs patient outreach and community liaison functions.  The telepsychiatry services include diagnosis, assessment, treatment, and case management. Treatment provided through these services include, medication management and psychotherapy (group, individual and family), as well as links to and coordination with other VA services.

Tribal Outreach Workers (TOW) are generally military Veterans and members of the tribes for which they serve and are employed by the VA. Their background enables them to foster trust and rapport with Native Veterans and reduces cultural barriers of the Telehealth Clinics. Their duties vary from assisting Native Veterans with determining their VA services eligibility, assisting with enrollment, scheduling intakes and appointments, orienting the patient on how to use the videoconferencing equipment, troubleshooting the technical aspects of running the telecommunications equipment in the clinics, to coordinating emergency crisis management. The TOW also works closely with the remote clinicians and provides guidance on cultural and community issues that may be relevant to a patient’s treatment or care.

The Center for Native American Telehealth and Tele-education (CNATT) is also housed within the CAIANH. This center organizes and focuses technological resources for Native American health from an array of telecommunications services to offer technical training, distance education, clinical care and research opportunities.

The Centers for American Indian and Alaska Native Health also produces a scientific journal, American Indian and Alaska Native Mental Health Research, three times a year.

“It contains empirical research, program evaluations, case studies, unpublished dissertations, and other articles in the behavioral, social, and health sciences which clearly relate to the mental health status of American Indians and Alaska Natives.”

Also at the University of Colorado Denver and under the National Center for American Indian and Alaska Native Mental Health Research (NCAIANMHR) was the American Indian Services Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP). The project’s “primary objective was to estimate the prevalence of psychiatric disorders (lifetime and current) and service utilization among two American Indian reservation populations that were aged 15-54 at the time the sampling frame was created. “ A number of projects were conducted to better understand the mental health needs of American Indians. One of these projects was the American Indian Vietnam Veterans Project (AIVVP) which examined the prevalence of post traumatic stress disorder (PTSD) and comorbid psychiatric conditions among approximately 600 Vietnam Veterans on four reservations in the Northern Plains and Southwestern United States.  It was the result of a Congressional mandate that the National Vietnam Veterans Readjustment Study (NVVRS)be replicated among American Indian, Alaska Native, Native Hawaiian, and Japanese American Vietnam veterans, ethnic minority groups that were underrepresented in the NVVRS. The AIVVP was part of a large multi-site study conducted to fulfill this mandate. Data collection was completed in April 1995 and funding for the American Indian and Native Hawaiian portion of the project was provided by the Veterans Administration (VA).

The VA’s National Center for PTSD conducted the Matsunaga Vietnam Veterans Project which extended the National Vietnam Veterans Readjustment Study (NVVRS) study to other minority Veterans. Spark Matsunaga, the late Senator from Hawaii, initiated this project to assess the readjustment experiences of American Indian, Japanese American, and Native Hawaiian Veterans of the Vietnam War.

The Matsunaga Project was comprised of two studies:

1. The American Indian Vietnam Veterans Project surveyed a sample of Vietnam in-country Veterans living on or near two large tribal reservations in the Southwest and in the Northern Plains. “These populations had sufficient numbers of Vietnam military Veterans to draw scientifically and culturally sound conclusions about the war and readjustment experiences.”
2. The Hawaii Vietnam Veterans Project surveyed Native Hawaiians (the indigenous peoples of the Hawaiian Islands)comprising around 22% of the permanent population in Hawaii, and Americans of Japanese Ancestry (the descendants of Japanese immigrants)comprising approximately  24 percent of the permanent population in Hawaii.

“The Matsunaga Study's key finding is that exposure to war zone stress and other military danger places veterans at risk for PTSD several decades after military service. Native Hawaiian and American Indian Vietnam in-country veterans had relatively high levels of exposure to war zone stress and high levels of PTSD. Caucasian and Japanese American veterans tended to have somewhat lower levels of exposure to war zone stress and later PTSD.”

Resources and References

General information:

“Chapter 6: American Indians and Alaska Natives.” Jay H. Shore and Spero M. Manson. In Pedro Ruiz, et al (Ed.), Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives.  (pp.52-61). Baltimore MD: Philadelphia, PA: Lippincott Williams & Wilkins. 2010.

“Chapter 10: American Indian Healers and Psychiatrists: Building Alliances.” Jay H. Shore, James H. Shore and Spero M. Manson. In Mario Incayawar, et al (Ed.), Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health. (pp.123-132). West Sussex, UK: John Wiley & Sons, LTD. 2009.

Conduct disorder, war zone stress, and war-related posttraumatic stress disorder symptoms in American Indian Vietnam veterans.
Denise Dillard, Clemma Jacobsen, Scott Ramsey, and Spero Manson.
J Trauma Stress. 2007 February; 20(1): 53–62.

Telemedicine/telepsychiatry and rural Native Veterans:

Building Blocks for Cultural Integration in the Development and Establishment of Rural VA Telemental Health Clinics for Native Veterans
This document presents a short overview, suggestions and tips for setting up, operating and maintaining Telemental Health (TMH) Clinics, in the form of live interactive videoconferencing, for rural Native Veterans located on American Indian lands or reservations, Alaska Native Corporations and communities, and Native Hawaiian and Pacific Islander lands and communities. Templates, trainings and videos are available to assist in the creation of agreements and collaborations, and operation of clinics.

Telemedicine for Anger Management Therapy in a Rural Population of Combat Veterans with Posttraumatic Stress Disorder: A Randomized Noninferiority Trial.
Leslie A. Morland, PsyD; Carolyn J. Greene, PhD; Craig S. Rosen, PhD; David Foy, PhD; Patrick Reilly, PhD; Jay Shore, MD, MPH; Qimei He, PhD; and B. Christopher Frueh, PhD
J Clin Psychiatry 2010 Jan 26. [Epub ahead of print]

Telemental health for our soldiers: a brief review and a new pilot program.
Nieves JE, Candelario J, Short D, and Briscoe G.
Mil Med. 2009 Dec; 174(12):xxi-xxii.

Family-focused therapy via videoconferencing.
Barbara M Dausch, David J Miklowitz, Herbert T Nagamoto, Lawrence E Adler and Jay H Shore
Journal of Telemedicine and Telecare 2009; 15: 211–214.

Trauma-Related Nightmares Among American Indian Veterans: Views From The Dream Catcher.
Jay H. Shore, M.D., MPH, Heather Orton, Ph.D., and Spero M. Manson, Ph.D.
Am Indian Alsk Native Ment Health Res. 2009; 16(1):25-38.

Telepsychiatry with Rural American Indians: Issues in Civil Commitments.
Jay H. Shore, M.D., M.P.H., Joseph D. Bloom, M.D., Spero M. Manson, Ph.D., and Ron J. Whitener, J.D.
Behav. Sci. Law 26: 287–300 (2008).

Acceptability of Telepsychiatry in American Indians.
Jay H. Shore, M.D., M.P.H., Elizabeth Brooks, M.S., Daniel Savin, M.D., Heather Orton, M.S., Jim Grigsby, Ph.D., and Spero M. Manson, Ph.D.
© MARY ANN LIEBERT, INC., TELEMEDICINE and e-HEALTH VOL. 14 NO. 5 JUNE 2008.

Attitudes toward medical and mental health care delivered via telehealth applications among rural and urban primary care patients.
Grubaugh AL, Cain GD, Elhai JD, Patrick SL, and Frueh BC.
J Nerv Ment Dis. 2008 Feb; 196(2):166-70.

Military and VA telemedicine systems for patients with traumatic brain Injury.
Philip Girard, MS.
Journal of Rehabilitation Research & Development; Volume 44, Number 7, 2007; Pages 1017–1026.

Diagnostic Reliability of Telepsychiatry in American Indian Veterans.
Jay H. Shore, M.D., M.P.H., Daniel Savin, M.D., Heather Orton, M.S., Jan Beals, Ph.D., and Spero M. Manson, Ph.D.
Am J Psychiatry 2007; 164:115–118.

An Economic Evaluation of Telehealth Data Collection With Rural Populations.
Jay H. Shore, M.D., M.P.H., Elizabeth Brooks, M.S., Daniel M. Savin, M.D., Spero M. Manson, Ph.D., Anne M. Libby, Ph.D.
PSYCHIATRIC SERVICES June 2007 Vol. 58 No. 6.

Cultural Aspects of Telepsychiatry.
Jay H. Shore, Daniel Savin, Douglas Novins and Spero M. Manson
Journal of Telemedicine and Telecare 2006; 12: 116–121.

A Developmental Model for Rural Telepsychiatry.
Jay H. Shore, M.D., M.P.H. and Spero M. Manson, Ph.D.
PSYCHIATRIC SERVICES; August 2005 Vol. 56 No. 8.

The American Indian Veteran and Posttraumatic Stress Disorder: A Telehealth Assessment and Formulation.
Jay H. Shore and Spero M. Manson
Culture, Medicine and Psychiatry 28: 231–243, June 2004.
© 2004 Kluwer Academic Publishers.

Telepsychiatric Care of American Indian Veterans with Post-Traumatic Stress Disorder: Bridging Gaps in Geography, Organizations, and Culture.
JAY H. SHORE, M.D., M.P.H., and SPERO M. MANSON, Ph.D.
© Mary Ann Liebert, Inc. TELEMEDICINE JOURNAL AND e-HEALTH Volume 10, Supplement 2, 2004.

Tribal Veterans Representative (TVR) Program

Tribal Veterans Representative (TVR) Outreach Workers “are appointed and supported by Tribal governments but formally trained by the VA; they function as liaisons between [V]eterans, the VA, and other community organizations. Made up primarily of volunteers, TVRs work closely with all agencies in the community to help [V]eterans obtain needed services to information and assistance completing paperwork for healthcare enrollment, claims benefits, education benefits, and home loan benefits.”  Veterans Rural Health: Perspectives and Opportunities. Department of Veterans Affairs; Office of Rural Health, VHA; February 2008.

The Tribal Veterans Representative is generally an American Indian or Alaska Native Veteran endorsed or sponsored by the Tribe or Tribal leaders and helps Veterans access their VA benefits. The TVR acts as a liaison between the Veterans Administration and Veterans and assists them with filing claims and/or other services they may need. They provide information, outreach and assistance to Veterans and their families, as well as resources that are available to them through the VA, the Tribal community, federal and state governments, and other non-VA sources. Training is provided by the VA, but TVRs are not VA employees. They are recognized representatives of a Tribal organization. Role of the Tribal Veterans Representative; TVR Resource Guide/Training Manual.

Representing the TVR program and providing training are W. J. “Buck” Richardson, the Minority Veterans Program Coordinator, Rocky Mountain Health Network (VISN 19) and the Montana Healthcare System in Helena, Montana; and James Floyd, FACHE, Network Director, VA Heartland Network (VISN 15), Veterans Health Administration. The TVR program began in 2001 and training is generally held the last week in April at Ft. Harrison in Helena, Montana. For more information, contact Buck Richardson at william.richardson@va.gov 

Download free viewer and reader software to view PDF, video and other file formats.