The US Health Care Delivery System

What changes in the U.S. health care delivery system would you suggest to actually make it a system in order to address the health

needs of veterans and their families, e.g. post-traumatic stress, brain injury, post-deployment depression, and other visible and

invisible wounds of war?

How do gaps in the system impact nurses and nursing care delivery?

Support your ideas or those of others with references from the professional nursing literature. Make sure to cite your resources and

include a reference list in APA style format.

References must be less than or equal to 4 years.

Reading
Course Text: Sultz, H. A., & Young, K. M. (2014). Health care USA: Understanding its organization and delivery (8th ed.). Sudbury, MA:

Jones and Bartlett.
• Chapter 1, “Overview of Health Care: A Population Perspective”
• Chapter 4, “Hospitals: Origin, Organization, and Performance”
Course Text: Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy and politics in nursing and health care (7th

ed.). St. Louis, MO: Elsevier.
• Chapter 19, “The Affordable Care Act: Historical Context and an Introduction to the State of the Health Care in the Unites

States”

Read the following articles:
First Article:
1.) What happens to the women who fall through the cracks of health care reform? Lessons from Massachusetts
Dennis, A., Blanchard, K., Cordova, D., Wahlin, B., Clark, J., Edlund, K., McIntosh, J., and Tsiktas, L. (2013). What Happens to the

Women Who Fall through the Cracks of Health Care Reform? Lessons from Massachusetts. Journal of Health Politics, Policy & Law, 38(2),

393-419.

We investigated the impact of Massachusetts health care reform on low-income women’s experiences accessing insurance and health

services, specifically reproductive health services such as contraception. Our findings suggest that concentrated efforts are needed to

make sure that health services are available and accessible to populations who fall through the cracks of health care reform, including

immigrants, minors and young adults, and women living outside urban areas. In addition, systems changes are needed to ensure that women

going through common life transitions, such as pregnancy, marriage, moving, or graduating from school, have continuous access to

insurance, and therefore health services, as their lives change. These groups face barriers enrolling in and maintaining their

insurance coverage as well as obtaining timely health care benefits they are eligible for through their insurance benefits or public

health programs. Without intervention, many in these groups may delay or avoid seeking health care altogether, which may increase

health care disparities in the long term. Family planning providers in Massachusetts have played a critical role in mitigating barriers

to insurance and health care. However, recent threats to defund family planning providers call into question the ability of these

providers to continue providing much-needed services.

Second Article:
2.) Sabella, D. (2012) PTSD among our returning veterans. How to recognize and assist veterans with this increasingly common mental

health disorder. American Journal of Nursing, 112 (11), 48-52.

PTSD Among Our Returning Veterans
Sabella, Donna MEd, MSN, PhD, RN
Author Information
Donna Sabella is assistant academic dean of health sciences in the College of Global Studies, Arcadia University, Glenside, PA. She is

the founder and director of Project Phoenix, an organization serving prostituted and trafficked women in the Philadelphia area. She

also coordinates Mental Health Matters: sabellad@arcadia.edu. The author has disclosed no potential conflicts of interest, financial or

otherwise.
Abstract
How to recognize and assist veterans with this increasingly common mental health disorder.Last April, while attending a U.S. Department

of Justice–sponsored symposium on human trafficking, I had the pleasure of being invited to lunch with Cindy McCain, wife of Arizona

senator and former presidential candidate John McCain. The small group lunch was organized to discuss current initiatives with Mrs.

McCain, who was also attending the symposium. However, before that conversation began, a different subject arose: veterans and their

mental health needs, especially those suffering from posttraumatic stress disorder (PTSD). Mrs. McCain’s son had recently returned from

duty and we found ourselves talking about returning veterans and some of the challenges they face, including PTSD. I was struck by the

fact that in spite of her “celebrity,” Mrs. McCain sounded like any other mother who had concerns about her child after his return from

combat; she was well aware that the scars can be emotional as well as physical.
________________________________________
Indeed, awareness of PTSD is growing; it appears that Americans are finally recognizing the urgent demand for more effective treatment.

Recent government efforts highlight this need. The Office of Inspector General of the U.S. Department of Health and Human Services

found that in 2011, 36% of veterans had to wait more than two weeks to access Veterans Administration (VA) care for mental health

concerns (two weeks is considered a timely wait period). This prompted a commitment by the Under Secretary for Health to “act rapidly

on all findings that may improve Veterans’ access to mental health care.”And, last April, First Lady Michelle Obama and Dr. Jill Biden

visited the University of Pennsylvania to announce the creation of Joining Forces, a White House initiative to support veterans and

military families. This initiative will train nurses working with veterans and create “more resources for veterans dealing with post-

traumatic stress disorder.”
While these are promising steps, only the universal efforts of all health care providers can help to ensure that those who serve get

the help they deserve once they return home. Unfortunately, veterans don’t always receive the treatment they’re due. Many avoid seeking

care because of the stigma associated with mental health disorders.Some live in areas that lack trained clinicians and thus may receive

an improper diagnosis—or even none at all. With more publicity and public discourse, hopefully this situation will improve. Since many

returning soldiers seek medical treatment outside the VA system, it’s important for nurses everywhere to be able to recognize PTSD and

to inform veterans and their families about resources available in their communities.

WHAT IS PTSD?
The emotional consequences of war can be severe. The human psyche is wonderfully resilient and capable of tolerating a great deal, but

there is a limit to what each of us can endure. Once that limit is exceeded, without appropriate treatment, there is often no turning

back. PTSD is in many ways a normal reaction to a traumatic event that exceeds the limit of what a person can tolerate.

PTSD is considered an anxiety disorder. It was first formally acknowledged in the Diagnostic and Statistical Manual of Mental Disorders

(DSM) in 1980. A PTSD diagnosis requires that a person has experienced, either directly or indirectly, or been confronted with, an

event that caused them to fear for their well-being or their life. The event may or may not have resulted in actual physical harm. The

DSM also specifies that PTSD may be caused by “witnessing an event that involves death, injury, or a threat to the physical integrity

of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family

member or other close associate.” In addition, the person must have experienced some level of fear, horror, or helplessness.
PTSD is characterized by the following symptoms: re-experiencing, avoidance and numbing, and hyperarousal.6For a diagnosis of PTSD to

be given, these symptoms must cause significant impairment and continue for longer than a month. Re-experiencing is the inability to

stop thinking or dreaming about the event; such thoughts can occur at any time and may be persistent and disturbing. The person may

also experience physiological reactions when exposed to cues associated with the trauma. Avoidance, as the word implies, causes the

person to make persistent and deliberate efforts to stay away from anything that reminds her or him, even remotely, of the trauma.

Numbing is often evidenced by feelings of estrangement or detachment from others, including family and friends, and can be evidenced by

a flattened affect. Hyperarousal causes a steady state of arousal and attention; the person may be constantly on guard and ready to

spring into action at any time. People with hyperarousal often have a heightened startle response as well as difficulty concentrating

and staying focused. They may appear irritable and overly angry at times and have difficulty falling or staying asleep.
While often associated with combat, PTSD is not limited to those in the military. Noncombat traumatic events that may lead to PTSD

include sexual assault, a life-threatening accident, being kidnapped or a victim of or witness to a crime, or living through a natural

or man-made disaster such as 9/11. However, it’s important to note that not everyone exposed to a traumatic event will develop PTSD. In

fact, most do not.
Prevalence in the general population. Estimates of PTSD in the general population vary. Breslau and colleagues found that the

probability of developing the disorder after traumatic exposure was 9.2%; the probability was 13% for women and 6.2% for men.Others

have placed the estimated lifetime prevalence of PTSD among the general population at 7.8%.Furthermore, what causes the disorder in one

person, veteran or not, may have no negative effects on another. There are, however, differences among various populations. Women are

more likely than men to experience PTSD and certain populations are more at risk.These include young adults; people with a history of

other psychiatric illnesses; and those who are single, divorced, or widowed.Sexual assault is the most common cause of PTSD in women,

whereas PTSD is most often combat-related in men.
Prevalence among veterans. PTSD is recognized as one of the most common disorders experienced by veterans returning home from combat.

While exact numbers are difficult to ascertain, especially since not all cases of PTSD in veterans are recognized or reported, a number

of studies offer insight into the prevalence of this disorder. In the 1988 National Vietnam Veterans Readjustment Study, researchers

looked back at the veterans of the Vietnam War and found that 27% to 31% experienced PTSD.More recently, the Walter Reed Army Institute

of Research Land Combat Study examined the rates of mental illnesses among members of the U.S. Army and Marine Corps fighting in Iraq

and Afghanistan. Findings revealed that three to four months after returning from Operation Iraqi Freedom, 12% to 13% of Marine Corps

and Army personnel, respectively, screened positive for PTSD and 16% to 17% screened positive for PTSD, depression, or anxiety. Twelve

months after deployment, 17% of respondents screened positive for PTSD and 21% screened positive for PTSD, depression, or anxiety.
Another study examined the prevalence of mental health disorders among 289,328 veterans of the conflicts in Iraq or Afghanistan who

used the VA health care system from 2002 to 2008.Of these veterans, 36.9% received mental health diagnoses and 21.8% were diagnosed

with PTSD. After the invasion of Iraq, the rate of new PTSD diagnoses increased four to seven times. The more time spent in combat, the

higher the risk of PTSD. Finally, the researchers found that those active-duty veterans who were younger than 25 years had higher rates

of PTSD and substance use disorder than their counterparts who were older than 40. The results of another recent study of veterans

returning from Iraq and Afghanistan supported these findings, concluding that those in the younger age groups were at higher risk for

being diagnosed with mental health disorders and PTSD than were active-duty veterans ages 40 or older. Aside from the mental health

issues associated with PTSD, Yaffe and colleagues found that veterans diagnosed with PTSD were nearly twice as likely to develop

dementia as those who never experienced the disorder.
Comorbidities. In one study of soldiers returning from Iraq and Afghanistan, researchers found that those diagnosed with PTSD had a

higher burden and risk of medical illnesses than those without mental health conditions.Chief among the medical conditions experienced

by male and female veterans with PTSD were lumbosacral spine disorders, lower extremity joint disorders, headache, tendonitis, and

myalgia. In addition, Iraq and Afghanistan war veterans with PTSD “were over four times more likely to endorse suicidal ideation than

those without PTSD”; this increased significantly in those with PTSD and two or more comorbid conditions.Finally, while high rates of

alcohol and substance abuse have been shown in veterans returning from Iraq and Afghanistan, rates were higher in those with

schizophrenia or bipolar disorder than in those diagnosed only with PTSD.
NURSING IMPLICATIONS
“Nurses are often the first people a veteran sees in any given clinical situation,” says Doris Vallone, PhD, RN, a clinical nurse

specialist who works with veterans in the behavioral health service department of the Philadelphia VA Medical Center. She encourages

all nurses—not just mental health nurses—to familiarize themselves with the signs and symptoms of PTSD.
Because not all veterans use VA facilities, nurses in all settings need to be prepared to recognize PTSD. Being aware of the available

resources, including those at local VA medical centers, is also recommended. According to Vallone, the VA is currently hiring

additional clinicians to work with people with mental health disorders and is open to exploring complementary and alternative

therapies—such as meditation, yoga, stress management, acupuncture, and relaxation therapy—and eventually using those supported by

evidence. Current treatment modalities include a variety of exposure and nonexposure cognitive-behavior therapies, and the judicious

use of select psychiatric medications.
Vallone also reminds nurses to remain aware of military sexual trauma (MST), which the VA defines as “psychological trauma… result[ing]

from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was

serving on active duty or active duty for training.”While MST has a higher prevalence among women, a comparable number of men and women

have experienced it. The VA provides universal screening and free treatment for MST to all veterans, both male and female.
Finally, it’s important to remember that PTSD affects not just the veteran but all those around her or him. “The effect on the family

is profound,” says Vallone. While reactions differ, some common emotions in family members that result from PTSD in a loved one include

fear and worry, sympathy, and anger and mistrust. Family members may also feel burdened if they are placed in the role of caregiver,

which they often are when the disorder is severe. In addition, there are often marital and relationship problems.Other common reactions

include drug and alcohol abuse, sleep and health problems, depression and anxiety, and avoidance of the person with PTSD.
The Primary Care PTSD Screen was developed for use by primary and other health care providers. It includes four questions that can be

answered either yes or no: “In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the

past month, you:
1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?”
Patients should be considered positive for PTSD if they answer yes to any three of the four questions. At that point a more thorough

assessment is recommended. Nurses with the appropriate training and job description may consider taking a more detailed history related

to their patients’ military background, experiences, and possible exposure to trauma. If doing so is beyond the nurse’s role, patients

should be referred to the proper mental health professional. It’s important to assess patients for suicidal ideation and whether they

could be a threat to themselves or others. Nurses can seek input from the patients’ significant others for further assessment of any

behaviors that could be possible indicators of PTSD.
Handouts about PTSD symptoms and treatment options—many of which can be found online at VA Web sites—are useful to share with patients

and their families (see Resources). For veterans seeking help at non-VA facilities, information about local veteran’s services and

treatment facilities (including the phone number of the closest VA center) should be available to distribute as needed.
Finally, it’s important to let patients know that what they are experiencing is a normal reaction to a traumatic experience and that

there are a number of treatment options, including various types of psychotherapy and psychotropic medications (some specifically

approved for treatment of PTSD). Reassure patients that they are not alone in what they are experiencing and give them hope that things

will improve.

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