There are currently 22 million veterans living in the United States. While 8.92 million veterans are enrolled in the Veterans Administration (VA) Health Care System, nearly 60% of veterans are relying on services outside the VA system (National Center for Veterans Analysis and Statistics, 2014). As such, it is imperative that civilian nurses understand service eligibility and veteran-focused care for this unique population.
It is a common misconception that all veterans are eligible to receive full healthcare benefits within the Veterans Health Administration (VHA). However, veterans are only eligible for health benefits if they meet specific requirements, such as certain minimum lengths of service and type of discharge as described below (Szymendera, 2015). Due to the specificity of these requirements, as well as the complicated eligibility process for receiving care in the VHA system, less than half of veterans receive healthcare services within the VHA system (National Center for Veterans Analysis and Statistics, 2014). Health disparities among this population have been well documented (Montgomery, Dichter, Thomasson, Roberts, & Byrne, 2015). Additionally, with the introduction of the Veterans Choice Act in 2014, veterans increasingly are accessing civilian healthcare services (VA, 2014).
Today nurses are at the forefront of the healthcare delivery system and are often the first to provide services to veterans. As nurses, we must be prepared to assist veterans in determining eligibility and understand how to help veterans navigate the VA system, so as to increase their access to care. A better understanding of this process can ensure high quality, veteran-specific patient care, and potentially decrease the health disparities within the veteran population.
Determining Veteran Status and Eligibility
The VA offers a variety of benefits to veterans of the armed forces, including multiple types of financial assistance, healthcare, housing, and education (Szymendera, 2015). To be eligible for benefits, a former service member who enlisted after September 8, 1980, must have served a minimum of twenty-four continuous months of active duty. There are no minimum service obligations prior to this date. However, health benefits for injuries incurred during active military service (service-connected disability) are exempt from this service obligation (Szymendera, 2015). Discharge criteria require that an individual be released from military duty with either an honorable discharge or general discharge (Moulta-Ali & Panangala, 2015). Although a dishonorable discharge automatically disqualifies an individual for VA benefits, other-than-honorable discharges or bad conduct discharges can be determined by special consideration (Moulta-Ali & Panangala, 2015).
Once former service members are determined eligible for benefits, their healthcare services are provided under a component of the VA called the Veterans Health Administration (VHA). The VHA is an integrated health system comprised of VA medical centers (VAMCs), community based outpatient clinics (CBOCs), community living centers (CLCs), Vet centers, and domiciliaries across the United States (VA, 2016). Veterans can receive a variety of services including primary care, specialty care, mental healthcare, and rehabilitative services. In response to both the growing need for increased veterans’ healthcare services and the rather recent whistleblower activity related to lengthy appointment wait times for veterans, the Veterans Choice Act was implemented in 2014. The Choice Act directs the Veterans Choice Program; this program allows for VA eligible veterans to receive non-VA care if they have to wait more than thirty days for VA care or if they live more than forty miles from the nearest VA medical facility (VA, 2014).
Veteran-Specific Health Needs
Today, in the United States, there are veterans seeking healthcare services who served during wartime and peacetime and from every major conflict since WWII. Each service period has differing characteristics affecting patient care services and health outcomes. For that reason, nurses must be extremely cognizant of the differing eras and varying effects of military service on the health of veterans. In general, veterans are exposed to hazardous materials that can be harmful to their health, including contaminated water, heat stroke/exhaustion, cold injuries, nerve agents, pesticides, endemic diseases, sand, dust, smoke, radiation, noise, fuels, asbestos, and industrial solvents (VA, 2015b). More information and a complete list of potential exposures can be obtained at the following website [http://www.publichealth.va.gov/exposures/index.asp].
Health Exposure Concerns
Chemical warfare agent experiments, cold injuries, nuclear weapons testing
Cold injuries, hepatitis C, nuclear weapons testing, agent orange exposure
Agent orange exposure, cold injuries, hepatitis C
Persian Gulf War, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), & Operation New Dawn (OND)
8/1990-Date determined by presidential proclamation or law
Animal bites, burn injuries, blunt trauma, shrapnel, spinal cord injury, traumatic amputation, traumatic brain injury, mental health issues, chemical/biological agents, immunizations, and infectious diseases
It is vital for nurses and other healthcare providers to not only understand the environmental exposures that veterans often suffer during service but also the psychosocial characteristics of the time period in which an individual served (See Table). For example, research has shown that Vietnam veterans suffer disproportionately, as compared to veterans who served during WWII and the Korean War (Fontana & Rosenheck, 2008; Villa, Harada, Washington, & Damron-Rodriguez, 2002). Vietnam veterans have reported both exposure to a greater number of atrocities and more difficulty with activities of daily living than have WWII veterans. They are also more likely to be diagnosed with post-traumatic stress disorder (PTSD) than veterans from the Gulf War and have higher rates of drug abuse compared to Iraq/Afghanistan veterans (Fontana & Rosenheck, 2008). The culture of the Vietnam War was different from that of other military time periods due to the unpopularity of the war in America, the large number of casualties, and use of conscription (in place of an all-volunteer force).
Veterans from the current conflict in Iraq and Afghanistan suffer from higher rates of PTSD than their Gulf War counterparts; yet they have the advantages of being younger, more likely to be working, more often married, and less likely to have a history of incarceration (Fontana & Rosenheck, 2008). Hence, veterans from the current war are often capable of socially integrating themselves back into society, which gives them a health-related advantage over veterans from previous wars. However, there is still much to be understood about the effects of the current war in Iraq and Afghanistan on the lives and health of veterans returning from this war since the conflict remains ongoing.
Some other health-related conditions among veterans that nurses need to know about include mental health conditions, such as suicide risk and substance use disorders (Kelsall et al., 2015); traumatic brain injury and women’s health issues (Kimerling et al., 2015, Miller & Ghadiali, 2015); depression, pain management, reproductive health, coping with chronic general medical and psychiatric conditions, sleep problems, weight management, posttraumatic stress disorder (PTSD) and homelessness (Kline, Callahan, Butler, Hill & Losonczy, 2009; Tsai & Rosenheck, 2015).
Because nurses represent the largest healthcare profession and work in a wide variety of locations and healthcare settings, they are likely to encounter some of the 22 million veterans living today. In order to provide high quality, comprehensive, and veteran-focused care, we encourage nurses to ask the following questions:
- When and where did you serve?
- What was your job while serving?
- How has military service affected you?
These questions have been developed by the Department of Veterans Affairs (2015a) for clinicians to use in practice. They provide clear direction for assessing a veteran’s health needs and guide nurses in providing the most optimal health outcomes. Being informed about veterans and their health needs should be a priority for all nurses. Learning about the health needs of veterans enables nurses to promote desired health outcomes among veterans and to positively contribute to their overall quality of life. It’s important that as nurses we diligently serve our veteran population, just as they have served us.
Angela Clark, PhD, RN