Blake Bourne of Veterans Bridge Home — AmericaServes community partner in Charlotte, NC — testified on Capitol Hill on empowering communities to serve veterans and military families through existing care systems. North Carolina has been leading the way in assisting veterans in navigating resources in their communities through IVMF’s AmericaServes program.

November 20, 2019

The Institute for Veterans and Military Families (IVMF) at Syracuse University is grateful to Chairman Takano, Ranking Member Roe, and the Members of the Committee for the opportunity to submit written testimony on the subject of H.R. 3495 and related Draft bill, to establish a pilot program for the issuance of grants to eligible entities to provide and coordinate the provision of suicide prevention services for veterans at risk of suicide, and in support of veteran families.

The research and programmatic efforts of the IVMF, over the past decade, have generated actionable insights into the social and economic determinants of veteran health and wellness, particularly as impacted by the service member’s lived experience navigating the transition from military to civilian life.  Since 2014, the IVMF has been meaningfully engaged in work aimed at improving the coordination of services for veterans and military families. Through the AmericaServes initiative, over 1,000 participating organizations in 17 communities across the country have helped over 30,000 veterans, transitioning service members, and spouses with over 65,000 requests for services, resources, and care. Given that the average client seeks assistance with at least two service requests, it has been essential for communities to have hubs empowered with the responsibility to facilitate efficient and appropriate referrals among a network of organizations spanning health and social service domains.

Central to the mission of the IVMF is the idea that the lived experiences of those who undergo transition from military to civilian life are critical to the long-term health and happiness of veterans and their families. Veterans and families who undergo successful transition are more likely to experience post-service health and prosperity. Conversely, a negative transition experience is highly likely to set a veteran and the veteran’s family on a compromised trajectory from which it is difficult to recover.[1] Additionally, circumstances and events occurring before, during, and after service may contribute to the stressors associated with suicidal ideation (financial instability, social disconnectedness, etc.).

With this context in mind, it is the belief of the IVMF that robust and well-coordinated support systems should underpin any efforts to improve the well-being of veterans and their families, and to reduce veteran suicide. This testimony will elaborate on three core ideas and practices that the IVMF has identified through the depth and scope of its AmericaServes work supporting and evaluating a diverse range of community coordination efforts across the country:

1. Criteria that position organizations to effectively coordinate service provision in communities;
2. Shared measures are critical to establish data-driven interventions to improve well-being;
3. Communities and coordination efforts benefit when given opportunities to share learning and receive ongoing technical assistance and evaluation support.

Criteria that position organizations to effectively coordinate service provision in communities

There are a number of important factors that may be used to identify appropriate locations for grant program funding to flow as part of a pilot program – concentration of veteran population, utilization of VA services and/or VA spending, suicide rates, etc. It has been the IVMF’s experience that there is no shortage of need for more robust systems of care; rather, there are other more qualitative conditions that should be in place, at least initially, when determining whether a community is “ready” to undertake efforts to coordinate resources and services. “Ready” is best assessed by two key considerations: 1) strong local leadership committed to changing how services are delivered, and 2) dedicated philanthropic resources to support (or supplement) coordination infrastructure. Grant dollars have the risk of being ineffective if applied to communities with stakeholders unwilling or unable to collaborate in a transparent and accountable way.

Additionally, as policymakers address the role of organizations who offer direct service provision or the coordination of service provision, the IVMF encourages a focus on organizations that demonstrate proof of the ability to take on hub-like activities. Across 17 AmericaServes communities, 17 unique organizations have taken on a hub role. These organizations are diverse in size, age, mission, and direct service offerings – making it apparent that successful hubs can be supported by any organization; however, not every organization has the capacity to support a successful hub.

The IVMF has adopted a set of important criteria organizations should meet in order to ensure efficient and effective service coordination and delivery to veterans and military families. These are:

• Expertise about benefits and resource eligibility – Comprehensive understanding of eligibility requirements for certain benefits and program will ensure clients get to the right provider(s), and conversely that clients are not referred to provider(s) who can’t help them.
• Referral management across resources — Experience coordinating services across agencies. Alternatively, demonstrates strong organizational history, staffing, and ability to stand-up and operate a coordination center within a community.
• Trusted relationships with community organizations — Established history of collaboration, partnership, and/or participation in local efforts to serve population needs. Also, local reputation and trust among providers and within broader community.
• Holistic intake of clients for needs spanning social determinants of health – Understands how certain needs co-occur and can assess and triage clients based on a spectrum of potential needs.
• Outreach to connect with veterans less likely to access care – Demonstrates track record and openness for connecting with hard to reach veteran subpopulations.

Organizations that have held these roles, or that exhibit clear potential and willingness to build capacity to do so, represent grantees well-positioned to make best use of federal dollars. In the experience of AmericaServes, these organizations do not necessarily provide an extensive list of service offerings spanning the social determinants of health (i.e., not one-stop shops). Rather, community hubs are most effective if there is a strong incentive to refer clients to partner organizations better suited to meet specific needs.

Importantly, coordinating services in a community helps create a no-wrong door approach to care that early evidence suggests is welcoming for difficult to reach populations. For example, AmericaServes disproportionately serves women veterans and minority veterans. Both are groups more likely to experience greater challenges at transition and beyond. Creating systems that are welcoming to underserved veteran populations increases the likelihood that they receive the services they need, and by extension, ideally contribute to suicide prevention.

Further, finding the right organization to steward federal grant dollars puts both federal and community resources to the first and best use. An example of this comes from our PAServes-Greater Pittsburgh network and one of the network’s most committed providers, Defenders of Freedom Pittsburgh (DOF).

DOF provides emergency financial assistance for transitioning Post-9/11 veterans. In 2018, DOF served 78 veterans and spent approximately $145,000. This year, DOF is on track to serve 20% more veterans yet spend 20% fewer dollars. This efficiency is due to the network’s ability to connect many of the veterans they served with other programs for which they were eligible, prior to utilizing limited philanthropic dollars through DOF. Pittsburgh Mercy’s ability to serve as a hub has fostered a healthy network that makes better use of programs like LIHEAP, SSVF, and disability compensation, while also leveraging the resources found in the community.

This example is one of many that demonstrates how creating a hub role within a community can serve to connect veterans to the programs that best suit their needs – which typically means existing public and VA programs first, reserving philanthropic dollars to fill in gaps and to provide support to veterans and military-connected clients not eligible for VA programs.

Shared measures are critical to establish data-driven interventions to improve well-being

A fundamental tenet of collaborative models that adopt shared systems is the commitment to identify shared measures, in order to use data analytics to track outcomes, reflect on the insights derived from those data, and adapt community priorities based on the evolving needs of the population. The IVMF supports this legislation’s inclusion of a key data collection and analysis component, in order to monitor progress, create responsive service delivery networks, and develop a common understanding of veteran well-being.

In the IVMF’s experience, once a common language and set of metrics are established, a phased approach has been an effective method to building community (local) and aggregate (national) measurement systems. Additionally, communities need tools that prevent data collection from being overly burdensome.

The first phase represents community-oriented measures. These are interim outcomes that help provide a more accurate/near-real time needs assessment and gap analysis for the community. These measures illustrate critical outputs such as service utilization by category, referral volume to providers, clients served, timeliness of care, and provider-reported service outcomes. This data would also offer insight into the needs and quality of services for understudied populations, such as military families.

Subsequent phases of measurement design should establish and monitor long-term improvements in quality of life. In addition to survey instruments to assess client well-being over time, evaluation activities may include collecting data with the potential of being connected to other rich federal datasets such as those produced by the Census Bureau, the Department of Health and Human Services, and the VA. In combination, these data can shed insight into outcomes associated with the physical, psychological, and social determinants of health that affect suicidal ideation.

Ultimately, the measure of success for this bill will be the long-term trends of veteran suicide. If the rate is reduced, especially in locations funded by this legislation or in locations with existing care networks, it would represent preliminary evidence of the efficacy of coordinated approaches in communities.

Communities and coordination efforts benefit when given opportunities to share learning and receive ongoing technical assistance and evaluation support

Improving the way veterans and their families connect with services, resources, and care is challenging work. Doing so requires an ongoing commitment of both financial and human resources across hundreds of stakeholders in each community, and the ability to continuously evaluate progress.

Platforms that support ongoing lines of communication between organizations and communities can be powerful mechanisms to address these types of challenges – creating space to share best practices and solve common problems to help advance the quality and effectiveness of care coordination across the country.

In AmericaServes, this infrastructure is called the Community of Practice (CoP). The activities and resources in the CoP provide a backbone for communities to work through complex cases, establish shared minimum standards of care, and collectively solve problems faced by multiple networks. Additionally, CoPs create opportunities for exchange between practitioners and analysts around insights derived from community data. The IVMF model to embed evaluation support into its programs has facilitated faster learning and the adoption of evidence-based practices due to open dialogue around the interpretation of data.

As this legislation is finalized, the IVMF recommends considering creating a robust technical assistance model, for example something similar to the offering within the Supportive Services for Veteran Families (SSVF) program, or to the cohort model utilized in the Institute of Museum and Library Services’ (IMLS) Community Catalyst Initiative. The IMLS program, in particular, offers an infrastructure for grantees to connect, increase capacity in key areas, and learn from their experiences.

These technical assistance models should also include evaluation and analytics support. Even if provided with tools for data collection, many community organizations do not have the internal capacity or expertise to analyze or report on required measures. The IMLS grant helpfully included direct evaluation support to complement whatever level of in-house effort could be applied.

Conclusion

Veteran suicide prevention efforts begin by ensuring that veterans have positive post-military experiences. These efforts require supportive solutions that build on the extensive fabric of organizations that already exist in the communities military families call home. The best data available, while likely incomplete, tell us that 17 veterans take their lives every day. 11 of those veterans are not in VHA care. This legislation importantly prioritizes and seeks to empower communities to connect veterans who are falling through the cracks of our existing care systems to the services they need, which helps the VA enhance its ability to meet its mission.

[1] Sonethavilay, H., Maury, R. V., Hurwitz, J., Linsner Uveges, R., Akin, J., De Coster, J. L., & Strong, J. D. (2018). Military Family Lifestyle Survey. Blue Star Families. Retrieved from https://bluestarfam.org/survey