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Joseph Bobrow

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What Works in Veteran Care: Confronting the Obstacles to "Joining Forces"

Posted: 06/05/2012 2:28 pm

In my last blog, I summarized the key needs that emerged during the Robin Hood Foundation's May 7 Veterans' Summit in New York. Here I want to tease out some obstacles to responding effectively to those needs that can elude even the most firmly committed. I've learned about these challenges while running a budding, now nationally recognized non-profit organization, the Coming Home Project, that has served 2,500 veterans, service members and their families and providers from 45 states.

I'll begin with a discussion from the summit that I omitted: Are operational stress impacts such as PTSD disorders with a "D," or injuries? The consensus was that the word "injury" conveyed more accurately the experience of war-related trauma and could help reduce the continuing stigma associated with facing problems and getting help. I agree.

I want to focus now on four of the summit's major themes: best practices, metrics, inclusivity, and creating a cultural "connective tissue" of veterans and civilians and their families.

Legislators have been pleading for years with the VA and DoD to research, identify and disseminate what were called at the summit "best of class" approaches. But VA and DoD are not permitted to "endorse" specific programs, so this became a frustrating, dysfunctional catch-22. Finally, in September 2011, the joint DoD-VA agency mandated and funded by Congress to study, identify and disseminate best practices for psychological health and TBI completed an exhaustive study that reviewed in detail thousands of reintegration programs and selected eight to feature in its comprehensive report.

It took seven months for the report to be made public and another month for it to be posted on the organization's website. For months, few if any of the decision-makers within DoD and VA, not to mention corporations and foundations, knew about the report's existence, not to mention its recommendations. When I mentioned the report to key legislators, they too were unaware of it and seemed, finally, after all the clamoring, to put little stock in this agency's findings and recommendations. (It was no small pleasure for us to learn that the Coming Home Project was the sole reintegration program that met the study's major criteria -- psychological, behavioral, social-family and spiritual -- while also having significant outcome data to back its effectiveness.)

Now we can see this as a simple information sharing problem and, in one sense, it is. But let's look at the related "metrics" factor. When I began to visit with potential supporters and funders, public and private, back in 2008 to brief them on Coming Home programs and interest them in partnering, the first question I was asked was whether we had evidence of effectiveness apart the scores of anecdotal data. It took us a couple years to gather such outcome data, but in the interim I learned that hundreds of millions of dollars had been expended, publicly and privately, on programs that had no evidence base to back up their effectiveness with their target populations. Why?

It takes vision and effort to embody the "we" culture so eloquently expressed at the summit by National Medal of Honor winner Salvatore Guinta. Blind self-interest, "I" motivation in "we" clothing, may belie eloquent wishes to "join forces." Unrecognized organizational stigma and fear of getting in trouble are additional factors.

Here's one of many examples that used to shock me but no longer does: The lead official in charge of a institution's programs to connect geographically dispersed vets said they could not invite a non-profit to apply for a pilot grant although they were certain the organization was eminently well qualified to provide needed services. The reason? Fear of getting in political hot water with legislators who favored a different program. One that did not, by the way, have outcome data to back it up. On one hand we have legislators screaming for "best practices" and on the other institutions that resist implementing best practices for fear of legislators' wrath. Who pays in such finger pointing stalemates? You guessed it; vets and families.

Now, on to inclusivity. Companies are increasingly interested in hiring vets, with talented junior officers in high demand. Mike Mullen encouraged companies to look to enlisted personnel as well. Many make the point, and rightfully so, that not all vets are suffering from PTS, TBI and related impacts of service. They have strengths to contribute to the workplace and the cultural commons. But what about those vets who are physically and emotionally injured, or cognitively impaired? What commitments are being made to adaptations that facilitate wounded warriors' successful contributions to the job market? Can we be "big" enough to go beyond the short-term narrow "I" focus and be genuinely inclusive?

Finally, I want to address the focus on "big top" programs: the inclination of many major funders and providing organizations, public and private, to sponsor mega job fairs, huge service projects, intended to bring out hundreds even thousands of vets, companies and community members and services. Today I received an email from the VA pleading for groups to refer vets to yet another a massive job fair, offering 15,000 positions across the country. Can we entertain the possibility that bigger is not always better? That vets and families may prefer other types of venues to connect with one another and with services in their communities?

The problems we face in health care, employment and housing are significant and approaches that can eventually "scale" are valuable. But it seems that many of these initiatives and the funding behind them are caught up in "bigger is better"; doing something, however un-researched it may be; or improving the brand of the particular organization or institution than supporting substantive change with proven approaches that are user-friendly.

If we want, in Tom Brokaw's words, to knit a societal "connective tissue," a community of civilians and veterans that welcomes home our troops and their families with an unconditional embrace of acceptance, we need to support grassroots, community-based, "bottom-up" programs as much if not more than 'big top,' top-down programs and public information campaigns. Excellence-based approaches are important, but I wonder if funders, public and private, can see the big "we" picture beyond the focus on the big splash, with its immediate spike in visibility, brand, sales and market share?

It is not just in tackling veterans' health care delivery, unemployment and homelessness that we need to question the conventional wisdom about what works. If we as a society are to broach the veteran-civilian divide, for example, addressed at the summit, we need social venues, optimal environments, where civilians and their families and children can get to know veterans and their families and children, up close and personal. Safe places of trust where we can "tear down this wall" that keeps us from the simple yet profound mutual encounter that is necessary for us to weave the connective tissue, together. And, as Paul Rieckhoff and Nancy Berglass reminded us at the summit, we need serious resources directed to such grassroots, community-based efforts.

 

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