Right to Care: Voices of Swords to Plowshares' Veteran Community

RIGHT to CARE:
Voices of Swords to Plowshares’
Veteran Community
MEGAN ZOTTARELLI
Senior Analyst
SWORDSTO PLOWSHARES
Institute forVeteran Policy
1060 Howard Street
San Francisco, CA 94103
www.swords-to-plowshares.org
APRIL 2016

In Section 202 of the Veterans Access, Choice, and Accountability Act (VACAA) of 2014,
Congress established the Commission on Care, charging it to examine veterans’ access to
Department of Veterans Affairs health care and to examine strategically how best to
organize the Veterans Health Administration (VHA), locate health resources, and deliver
health care to veterans during the next 20 years. Michael Blecker, Executive Director of
Swords to Plowshares, is a commissioner.
In order to amplify the veteran narrative within the Commission on Care deliberative
materials, Swords to Plowshares investigated access to VA and non-VA systems-of-care,
and measured perceptions of the quality of services among the Swords to Plowshares
veteran community. We conducted one-on-one in-depth interviews with 22 veteran
clients and staff who have accessed VA care locally and throughout the country using a
human-centered design for our user research.
2

Main Research Questions
War causes wounds and suffering that last beyond the battlefield. Swords to Plowshares’
mission is to heal the wounds of war, to restore dignity, hope, and self-sufficiency to all
veterans in need, and to prevent and end homelessness and poverty among veterans.
“How would you assess your overall health?”
“To what extent do you rely on VA for care? To what extent do you rely
on care outside the VA?”
“Are there any needs not being met by your current level of care?”
“How comprehensive is your care?”
“How do you navigate VA care?”
“How would you rate the quality of care you are receiving?”
“How important is VA care to you?”
3

Research Design
 HUMAN CENTERED DESIGN
 CONTEXTUAL INQUIRY
 USER RESEARCH
 METHODOLOGY: 22 in-person or by phone
individual conversation style interviews. Client
participants were recruited through case managers.
We met with veterans individually in a convenient
space: Swords to Plowshares offices or housing
units, or at the veteran’s workplace.
4

Research Population
1
4
5
1
9
2
1 8 - 2 9
3 0 - 3 9
4 0 - 4 9
5 0 - 5 9
6 0 - 6 9
7 0 +
AGE
17
4
1
M A L E
F E M A L E
T R A N S
GENDER IDENTITY
14
5
3
V E T E R A N C L I E N T S
V E T E R A N S T A F F
V E T E R A N
S T A F F / C L I E N T S
VETERAN RESEARCH
POPULATION
2
8
2
4
6
A I R F O R C E
A R M Y
A R M Y N A T I O N A L
G U A R D
M A R I N E S
N A V Y
BRANCH OF SERVICE
5

Research Population
ERA(S) OF SERVICE
5
5
5
8
0
1
1
0
I R A Q / A F G H A N I S T A N ( 9 / 1 1 / 2 0 0 1 - P R E S E N T )
G U L F W A R I ( 8 / 1 9 9 0 - 9 / 1 0 / 2 0 0 1
P O S T V I E T N A M ( 1 9 7 6 - 7 / 3 1 / 1 9 9 0 )
V I E T N A M ( 1 9 6 4 - 1 9 7 5 )
P O S T K O R E A N ( 1 9 5 6 - 1 9 6 3 )
K O R E A N ( 1 9 5 0 - 1 9 5 5 )
P O S T W W I I ( 1 9 4 6 - 1 9 4 9 )
W W I I ( 1 9 4 1 - 1 9 4 5 )
6

Research Population
13 served in combat zones or areas or hostility
SERVED IN COMBAT ZONES ORAREAS OR HOSTILITY: 13
Vietnam: 3
Iraq Gulf War: 1
Iraq Post-2001: 4
Afghanistan: 2
Bosnia: 1
Other Areas: 2
15
5
2
A L L V A
C O - V A
N O N - V A
FOURTEEN HIGHER-ENDVHA USERS
 Dependent solely on the VA for primary,
specialty, and mental health
 What VA’s Center for Innovation refers to as the “Lifer”
or “Transactional” user
 Older veterans, have used the VA longer
SIX LOWER-ENDVHA USERS
 Emergency care
 Infrequent users, co-enrolled
 What VA’s Center for Innovation refers to as the “Just-in-Case”
or the “Infrequent”
 Recently separated veterans, those who have used the VA for
a shorter time
7

VA User Levels
Veterans interviewed rely in varying degrees on the VA for their primary, specialty, and mental healthcare. Overall veterans
reported an average of three providers. A large number use VA as their provider for all care. Few are co-enrolled and will use the
VA selectively. Others will use the VA as a safety net for urgent situations or only when they are extremely ill. A few, including
those with less than honorable discharges who’ve been deemed ineligible for the VA only access the VA for emergency
circumstances.
The veterans we spoke to rely on VA care for various services. Younger and healthier veterans most typically seek care from VA
for emergency needs, relying on VA care as a safety net. Those with more serious health concerns will seek care and tend to rely
more heavily solely on VA care. Those who are co-enrolled more typically have a primary physician outside of VA care, and seek
mental health services from the VA.
“Out here, I've seen the most doctors ever. I'm going to the PTSD
education class. I'm seeing Dr. [name removed for anonymity], the
psychologist. I saw [name removed for anonymity]...he's like a PTSD
specialist. Then I see Dr. [name removed for anonymity], but I couldn't get
her today because I was feeling so bad...I couldn't get out of bed. I called
them to let them know. Then Dr. [name removed for anonymity] is my
primary doctor...and I would see a pharmacist...She helped me with my
diabetes, with the insulin. And like I say, I'm going to see a dentist, and
then I'm going to see a couple of different doctors up in Martinez. I haven't
been to Martinez in a really long time.”
“I've got one [provider] for mental health, I've
got two primary doctors, and I've got one for
the eye. I've got one for podiatry, I've got one
for my hands. So I've got a crew.”
INTERVIEWER: “Where do you get your healthcare?”
VETERAN: “Mainly from Kaiser.”
INTERVIEWER: “OK, and you mentioned you also get it from the VA?”
VETERAN: “I also...yeah, I get mental health services from the VA.”
“I usually only
go to the VA for
emergency
circumstances.”
“I don't have any like scheduled
checks or anything, but the few
times when I've gotten really
sick, I eventually…I'll go over
there if I really have to. But I
don't go there very often.”
8

Findings: Health and Care-Seeking Behavior
SELF-PERCEIVED HEALTH STATUS
Insights on personal health show veterans regard
themselves as both physically and mentally fitter than
what their stated conditions and healthcare needs may
imply. Self-perceived health status is an important
determinant of identified need (and demand) for
healthcare and other health-related services. This
appeared to impact how they access healthcare services
(i.e. they don’t access until they’re in crisis).
“I'm in good health, because I just had blood work...I just have
arthritis in my right knee, but overall, I guess I'm okay.”
“Right, so you break it down a little bit. So I just had eye surgery.
I had an operation on my left knee. I have a couple pending with
my wrists and hands, but overall, after all of that, I'm okay.”
“Compared to my veteran peers, it's good, but compared to my
civilian peers, I'd probably say...adequate.”
“Good, my health's good. Not excellent...there's always room for
improvement...it's good. It's not poor.”
“I have good hours during the day. They've given me an 80
percent rating, and 20 percent is pretty damn healthy.
“I have had diabetes, so I would say it's actually pretty good.
And my mental health is getting better. I'm going to counseling
for the PTSD. I have a claim in for it, too. ...after 47 years.”
RESTORING HEALTH DURING INJURY/ILLNESS
RATHERTHAN FOCUSON PREVENTATIVECARE
The majority of research participants focus on relieving
illness and symptoms rather than preventative care. This is a
similar behavior to patients in the private sector, but military
service, culture, and trauma complicate this even further.
Onset of physical symptomology can be an emotional trigger
of trauma, especially if veterans feel the symptoms are
service-connected, and they may feel additional stress and
the desire to have their symptoms substantiated
immediately.
“If any new issues arise I would [like to] have a fast and easy way
of getting in touch with whoever's helping me so that we can
resolve that situation a lot faster.”
9

Findings: Care Quality
RATINGSOFVA CARE QUALITYAND IMPORTANCE OFVA
Most veterans rated their VA care quality as favorable, in spite of the administrative hurdles they cite. While veterans tend to regard care
experience and timeliness of care as unexclusive, and in fact care standards for these veterans encompass the wait time that they experience,
even those who mention lengthy delays and problems with certain care still mostly reported a high rating of VA care quality. Some reported
timely access and easily coordinated care through their network of providers, which appeared to influence favorable ratings of VA care
significantly, as predicted. When we asked them to describe how comprehensive their care is, veterans interviewed typically cited waiting for
VA benefits claims as the primary hindrance in getting all of their needs met, followed by getting referrals for needed services.
6
7
2
1
2
1
1
2
U N B E N E F I T E D
W A I T I N G O N C L A I M
2 0 P E R C E N T
3 0 P E R C E N T
5 0 P E R C E N T
6 0 P E R C E N T
7 0 P E R C E N T
8 0 P E R C E N T
VA DISABILITY
COMPENSATION
RECEIVERS
NONE
“I would say that overall, my care through the VA has been excellent. I figure it seems to
be pretty good. Whenever I have something going on that I need to talk to my doctor
about, I do that. I have regular diagnostic tests scheduled, and I go to those. If anything
comes up, my doctor looks at it and makes that referral. So I would say my care is pretty
comprehensive. If there is something going on, and I talk to my doctor and explain how I
feel and what's going on, there doesn't seem to be any problem with scheduling a
diagnostic test or sending me to whatever medical specialty I need to talk to.”
“Well, I have some things that I go through...quality of life, issues that if I didn't have
access to VA medical care, my quality of life would be really impacted because I don't...if
I didn't have that care I wouldn't be able to afford to pay for it.”
10
“I'm amazed at how this place works. I know it appears that they have problems almost every day of people being dissatisfied with this and
dissatisfied with that. But not me...I appreciate it.”
“It's real excellent because…. there's no long waits, so I get in right away when I go up there. No, the VA takes good care of you. They're taking
real good care of me. If I didn't have the VA, then I would be kind of worried about my health because I'm getting old, getting up in age…”
“You know, by and large, I would say, when I do get care at the VA, it's very good care. You know, the residents out there, the students from
UCSF, they are great. But getting an appointment with anyone is nearly impossible.”

CONTINUITY,COMMUNICATIONAND COORDINATION
The VA care team is important to the veteran. Veterans desire and expect a meaningful relationship with their medical providers,
and for their team to have a meaningful relationship as well. To them, their relationship with their providers is both a validation of
their military service and an affirmation of trust, the tenets of which are communication, referral and coordination through their
network. Veterans who have multiple providers, even those who receive care outside the VA, want their providers to share
information amongst themselves so that the veteran doesn’t have to keep informing and advocating on their own behalf.
Some mentioned seamless referral and coordination at the VA when they felt that their care team was communicating thoroughly
about their health needs. Conversely, veterans sense when they are not being referred in a timely and coordinated manner, and it
affects their care experience and relationship with their provider significantly. Overall, though, veterans on both end of this
spectrum recognize that this integration of multiple care competencies is a distinctive quality of the VA, most especially that
specialty care is complex and identification and treatment of these conditions requires providers to work closely together.
“I think because they have a knowledge of veterans, they can realize that there's more than meets the eye. Like someone even going to the
dental, all of a sudden they are having a nervous fit, and they are just getting their teeth cleaned or something. Well, they can realize there's
more to it than that...maybe there is something they should go see mental health for.”
“They've been helping me...I now have high blood pressure I have to worry about. Dr. [name removed for anonymity] has just been
wonderful as far as regularly testing me, to make sure the medications I'm taking are the medications I should be taking in the right doses,
and making sure I have enough. And even providing his own cell phone number, when I would have trouble getting a medication… Dr.
[name removed for anonymity] is just like being with a civilian doctor...he has his official number, but then he has the number he's given me
access to in case I have problems in getting the medications I need to get. So, he's just been super.”
“Especially as you get to know your care team over time, that relationship continues to build...unless you actually move a lot, that
relationship only deepens and gets better… Since I've been diagnosed with traumatic brain injury, post-traumatic stress disorder, and
chronic pain…there's a lot of overlap in symptoms and conditions, so it's very hard to pinpoint the difference and the nuance in what one
might be affecting them. Outside providers might be specializing in one but not two or all three. At the VA, they recognize that and talk as a
team for your care and procedures. The specialists, when I actually get to see them, have been phenomenal and always accommodating
and work with you and actually talk with you about the issues and break it down to a level so you can understand and make the best
decision moving forward.” 11

PATIENT EXPERIENCE: A RIGHTTO CARE
Veterans feel a right to veteran-specific care as a matter of respect for their military service, and an expectation that military
service gives them this access to VA care. This right to care is expressed through a preference for VA/veteran-specific care over
private care regardless of their own particular care quality. The VA has created an expectation for providing this service, and
veterans feel upset when the VA fails to deliver certain care.
Patient experience encompasses much more than simply care quality and access; veterans access the VA because they feel a
connection to their service, they feel it’s their right, and thus their experience includes feelings of veteran identity, and a
connection to that identity. A positive patient experience leads to a greater sense of respect to their service and their veteran
identity. Contrary, when there are problems in their care quality or access they not only feel dissatisfied with their healthcare,
but they feel a disrespect to their service and their veteran identity as well.
“Overall I would say my experience with the VA has been good. I've had some challenges. But I'm also a huge advocate of the VA.”
INTERVIEWER: “Is it important that it's veteran care specifically or are you just, I just want care and as long as it's good?”
VETERAN: “Well, it's...the old adage is, once you put the uniform on, you're always going to have that uniform, no matter what. That's part
of the unity of the military, and if you've ever been a military brat, which I am, and which my mother was, you never let go of that. That's a
part of your anatomy anyway is your military. As far as civilians going along into veterans hospitals, I wouldn't have any problem with that
at all. But as far as if I am going to go to a hospital like General or UCSF, I would have a problem with that. And it's not just because of the
fact that I really didn't get the care I should have been getting or that my mother didn't get the care she should have been getting either
place or anything of that sort...it's the fact that you're still wearing that hat of the military and it's imbedded in you...it really is. A lot of
veterans feel like I do...this is my hospital, this is my family, this is where I belong. I don't belong over there in UCSF or someplace else. And
even though there are doctors from the outside who come to the VA, the VA to me has always impressed me not just because they are so
big, it is because they are so caring. Because there is no other facility that is quite like a VA facility. And I've dealt with a lot of hospitals over
the years.”
12

TIMELINESS—EXPECTATION FOR IMMEDIATE CARE, ESPECIALLY AMIDSTTALK OF DELAYS
There is an expectation among the veterans in our sample that once a health issue emerges, they should receive immediate care.
This is not an unrealistic expectation, and is a similar opinion among patients in other healthcare systems, but it does carry a
knock-on effect given the complexity of their service-related health needs. Their health seeking behavior indicates that those who
have delayed seeking care due to stigma, inaccurate self-health perception, low expectation of VA care, other factors, rush to seek
care once any symptoms emerge. Coupled with issues of timeliness the VA has experienced leads to a perceived anxiety among
the interviewees when an illness or injury occurs that they won’t get the care they need. While some veterans interviewed have
this expectation of waiting tend to build in time into their schedule to wait for appointments, knowing and preparing to wait
increased their anxiety significantly, especially those seeking specialty care or mental health appointments.
Veterans see the wait time issues as systemic, but it was unclear whether their personal experience influenced this perception, as
some who reported wait times as a VA system-wide problem said they themselves do not deal with lengthy delays. Many have
differing experiences based on location and healthcare need. Many view issues with timeliness as a failure to meet demand for a
certain healthcare need more than others, not in failures to meet overall care standards.
“Yeah, the VA clinic was really easy...I mean they always took care of the problem. Once I got in the program there, it was excellent. I never
had a problem...but it just took a long time.”
“With the specialists, especially when it comes to some chronic pain management issues, especially like the neck and spine surgeon, and
getting the appropriate tests done for that, did take a considerable amount of time. It took months to get the proper testing done and also see
the appropriate specialists...just because the VA was overwhelmed with the amount of requests they were getting at the time. It wasn't their
inability to actually process, just for the amount of demand that was going through...but once you got through, they were phenomenal in
getting you through the process.”
13

NEED FORTREATMENT CONSISTENCYACROSS MULTIPLE LOCATIONSAND PROVIDERS
Veterans who have accessed care from multiple VISNs stress the importance of streamlining enrollment, patient information, and
referrals to new doctors across medical centers. The migratory nature of some veteran populations makes accessing care more
difficult, and there is an importance of maintaining records and providing consistent care across centers. Some stress through
personal experience as well as hearing from other veterans that there is inconsistency in treatment quality among various
providers within medical centers. This is especially frustrating for veterans who are receiving specialty care, and places additional
burdens on the veteran to self-advocate.
“I had to re-register because I was with Oakland, but not with San Francisco and they did all the paperwork. They went out of their way to
accommodate me…they found out how to do it and everything like that since my main care provider was Dr. [name removed for anonymity] in
Oakland, and I thought about doing it here, because I have office hours in Oakland, I mean San Francisco, after doing the office hours at the VA
there, I wanted to do blood work, which I had to do anyway. They were just marvelous and everything they did in arranging it.”
“The services and everything seem actually very thorough for the physical side in Illinois. When I went there for the first time, they did like a top-
to-bottom physical check. They did like x-rays, they did all these things I've never taken before...x-rays, all these different body scans, literally all
the same day. And it seemed like it was a relatively fast. I've also basically had the similar experience here at this VA [in San Francisco]. Any
time I have been sick and gone to the ER, which has been, I think, once now, it was relatively quick. They did some blood tests and stuff like that
and then gave me antibiotics. I have to say that it's decent. It gives me what I need.”
“Sometime I'd be on the street...sometime I'd miss appointments. Being in one place, it's a lot easier to get everything done…I've been back
here for about 30 years or more. I started driving a cab here in 1971. Then I went up to Seattle, back and forth. I moved around a lot.”
14

STAFFTURNOVER HICCUPSCARE
Veterans who reported the same provider over a longer
length of time tend to view their relationship with
providers as more favorable. Veterans who reported
changes in their providers reported a hiccup in care and
frustration with having to repeatedly explain their health
history to providers. This turnover fractures their
relationships with providers and leads to less favorable
views of their provider.
“My experience the second time going back wasn't as smooth. I
remember...I met with an emergency care provider who wasn't
my primary care…She ran through like the litany of questions,
drug abuse, medications and everything else. I sat in her office
for an hour before that and she never once looked at the one
thing I came in there to look at. Maybe it wasn't her
fault...maybe she just had to run through all these questions
and get through this process of stuff they have to get through.”
VETERAN: “I have to see an endocrinologist every year. For ten
years, it's been a different person every single time.”
INTERVIEWER: “Ah, okay. So it's not the consistency that you
need.”
VETERAN: Absolutely, and it's a whole new introduction getting
to know that doctor. It's ridiculous.
RATINGSOF MENTAL HEALTH QUALITYAND
NEED FOR INDIVIDUALIZEDTHERAPY
MODELS
Overall, quality of mental health services was reported as
somewhat favorable among the veterans we interviewed,
however, mental health treatment specifically for PTSD is
reportedly largely focused on group therapy, which works
for some, but not all veterans. For instance, women
veterans report that group therapy is a way to validate their
own experience by hearing from others with similar issues.
Veteran men tend to find group therapy triggering.
Interestingly, those with comorbid diagnoses report they are
able to get individualized care for those illnesses (bipolar
treatment, substance use rehabilitation programs) more so
than for PTSD. Despite these challenges accessing individual
therapy for PTSD, most of the veterans don’t want to seek
care for PTSD outside the VA.
INTERVIEWER: “How important is receiving VA care to you?”
VETERAN: “It's very, very important…”
INTERVIEWER: “So are there any services that you receive from VA
that feel like you can't get outside of the VA?”
VETERAN: “Definitely, most definitely PTSD counseling. Marriage
counseling or family counseling, so that my family can understand
what PTSD is and why I have the nightmares I have and why I go
through what I go through.”
15

RATINGS OF MENTAL HEALTH QUALITY AND NEED FOR INDIVIDUALIZED
THERAPY MODELS, cont.
“I had a lot of trouble both emotionally and mentally dealing with it. I did seek out help through the mental
health clinic...it was some of the best mental health professionals I've ever dealt with.”
“The coping group was a women's group that I got to go to every week, and it would be me and a couple of other
women veterans where we would meet for an hour. It was like a focus group where at the start of the group we
would start with a breathing exercise, a meditation exercise, and they would start a topic, and each week would
be a topic of different things. I think it really helped, because the group was about how to deal in social
interactions with others and having to deal with the PTSD. But yeah, I guess that's the best way I could explain
it.”
“I seek counseling therapy through the Vet Center, and the lady I see there has been a tremendous help. She's
been really supportive…yeah, she's been really amazing.”
VETERAN: “I went out [to the VA], I was assessed, they agreed that I had PTSD, and they put me in a group. I
went to that group twice, and called them and said, ‘I'm never coming back.’ So...”
INTERVIEWER: “What was the experience like if you don’t mind me asking?”
VETERAN: “Triggering. They try to stay general. It was a group therapy, and I'm just not willing to talk about my
experiences in a group, and the people who did talk about their experiences in group triggered me. And so, my
sleep was shot...my nerves were shot. After the second session, I just said, I can't, I can't deal with this here. I
think if I was able to deal with it one-on-one, with a therapist, I could probably do that. But I can't do it in a
group, and that wasn't an option for me at the time.”
“[Mental health practitioners outside of the VA] were not able to deal with the PTSD. I feel like to some
extent...whether it's in the VA system or outside the VA system, that is just not being dealt with or not being dealt
with adequately.”
16

MOST NEEDY POPULATIONS MOST AFFECTED
The veterans most in need of healthcare report to be most affected by administrative hurdles, and by failures to provide care that
is tailored to their actual living conditions. They feel the VA system should be designed specifically for their service-related
injuries and that those more pressing should take priority in terms of scheduling and availability of doctors. When these services
are considered dire, waiting for an appointment seems especially difficult to these veterans. Critical to their livelihood, these
populations feel particularly reliant on the VA for their care.
“I would like to have access to my doctor 24/7, somehow, so if I woke up in the middle of the night and had a scary nightmare, I could call
them or page them to where they would call me back and we could talk about that nightmare right then and there. You know what I mean, so
they could walk me through it so I could fall back asleep easily or fall back asleep with some kind of ease...or also have too a perfect scenario
would be if I ran out of my medication, I could go to the VA anytime day or night seven days a week, 24/7, and walk in there and say, ‘Hey, I'm
out of my medicine’, and they could provide that right away. I mean they are just really, really slow, and by the time they get to you, the
problem has either worsened or it's gotten completely out of control to where...I wouldn't say you can't help it now...but it gets to the point
where you get those suicidal thoughts back, and it's a thin line, and it happens to me and it happens to other veterans I know. And yeah, they
do have that VA hotline, where you call them...but you know talking to someone about your issues that doesn't know you and has never met
you, and all they're telling you is put the knife away or hey, put the gun away. It's not worth it. It's cool that they have that, but I feel like each
veteran should be able to communicate with their doctor like that in a way...like they should have a 24-hour, 7-day a week kind of thing.”
“I was sick for four and half months. I would call and try to get an appointment with my primary care provider, and they would say, ‘We have
something six weeks out.’ She doesn't even have drop-in available until then. You can come in and see a different doctor. Trying to get
referrals from my primary care physician...just for example, recently for GI work, took four months. I tried to get a referral for vision probably
starting in February of last year, and I just got a message from a nurse who said they'd sent it to a doctor who was going to try to refer me out
to vision. So, if you're good and healthy, and you’re going in for regular checkups every three months, it's great. 'Cause you see them, they
hand you a slip, they give you a date right then and there for your next appointment and you are set to go. If anything comes up, forget it.
When I was sick most recently about two months in, I lost my hearing, and it took me two and a half months to get a referral to audiology.”
17

Findings: Choice
INTEREST IN CHOICEANDVA OBLIGATIONTO PROVIDECARE
Most interviewed were ineligible for Choice, and while
some had utilized Choice or purchased care (most often a
one-time use), veterans feel like it’s a failing of the VA to
provide that service. Many expressed anger at having to
utilize care outside the VA. This was most common among
veterans needing specialty care. Most veterans seeking
care from the San Francisco VA Medical Center, which is
considered to provide comprehensive services, and who
live locally, stated they would not utilize Choice, perhaps
telling that when local resources are available at the VA
they are less likely to seek non-VA care.
A few that had become fed up with waiting for
appointments said they would be interested in Choice.
Two stated they would like utilize Choice for mental health,
specifically PTSD treatment, but were unable to find a
private psychologist who would accept the Choice card.
INTERVIEWER: “Once you do get [Choice], would you
anticipate.… expanding your usage of it or would it just be for
these things that you are having trouble accessing at the VA?
VETERAN: ”I think I'd use it for allergist. I look into using it for
some sort of therapy where I'm not with other veterans, because
the atmosphere of group therapy there can be really weird, to
say the least. That would be the only thing.”
While some veterans’ use of the VA is be limited, many
veterans expressed strong views about the obligation to
provide care for veterans. Many veterans interviewed feel
the VA has created an expectation for service quality. If the
VA stops providing this standard of care by allowing another
provider to provide that service, according to the veterans
interviewed, they will feel very strongly that something has
been taken away from them. This apprehension and
concern that changes could diminish care was a recurrent
theme among the interviewees.
“I'm ineligible due to the current regulations on the VA Choice
card being...living in the City and County of San Francisco, and I
also haven't seen a pressing need to seek care outside of the VA
because when you actually get to see the appropriate personnel
they’re great with what they can do, it's just that they don't have
the amount of staff to facilitate the amount of requests they are
getting.”
18

Findings: Veteran—Provider Relationship
THETRUST PARADIGM
Perceptions of trust and mistrust in the provider-patient relationship are similar to civilian patient-doctor experiences and
relationships, but is amplified given the nuance of military service and the complexity of injuries lack of available military health
and service records from the Department of Defense, leaving the burden on the veterans to provide evidence of the traumatic
stressors, and cultural competency of the provider. Mistrust is sometimes perceived by veterans FROM doctors and leads to a
poorer patient-provider relationship.
“I was under the assumption they would
have me do some type of Agent Orange
physical, which never happened. They then
scheduled me to see a psychiatrist in
Martinez, and I went and saw the
psychiatrist at Martinez and spent probably
about 45 minutes with him. And that was
the extent of that. I received a letter from
the VA saying that they again did not
consider my bladder cancer Agent Orange-
related but that they were giving me 30
percent for PTSD. They don't recognize
bladder cancer as being Agent Orange-
related yet. They say, it's on their list, but
right now, it's not considered. Which, yeah,
is beyond me.”
“When I originally got out of the
military, they said that those who
served in Vietnam would get full
medical VA, so I used my VA, and then
when they changed the regulations, I
switched over to Kaiser, because I was
a city and county employee and I could
get Kaiser for free. Then when my
bladder cancer came up, I put in a
claim with the VA. They denied the
bladder cancer, but gave me 30
percent for PTSD.”
19
“When I go in, there's a level
of defensiveness, a level of
mistrust that I experience. And
I'm insulted by it, when I'm not
trusted by my doctor, and I tell
them what's going on. [They
say] ‘Oh, we're seeing
something different.’ I'm like,
‘No, I'm telling you what's
going on.”

Providers who are also veterans are perceived by veteran
patients as much more knowledgeable with a direct
understanding of the military and veteran experience.
There is an increase of trust as a result.
“It's a wonderful feeling...it's just like when we supported each
other when we was out in the field...or you know, in these
combat areas and stuff like that...supporting one another, and
you know that's important to have support and to be there...it
makes you think you have a brother.”
THETRUST PARADIGM, cont.
Veterans seeking VA benefits feel particular mistrust if their
military service records or evidence-based research
regarding their health do not align with their account of
service-related injuries. They feel the VA should act as an
advocate on their behalf rather than rely on service records
which may be inadequate in some cases or, in others,
inaccurate representations of the events that led to service
connection.
“And my attitude in the last few times I've gotten on the 38 to go
there and I've been just irritated and pissed and upset when I get
there. I'm like, I'm here...I'm on the 38 going to Fort Miley for the
like the 450th time literally. Now that I know it's caused by
chemical exposure in the Marine Corps, which they ignored for
two decades, and lied about, and the whole story is horrendous.
So I get there and I'm angry now. So my attitude is a little critical
of the care.”
“I was a spray painter, too. In those days, they had like lead... I got emphysema from that. They keep on denying me from that thing...they say
that I got it from smoking, but I was in there for only a year and four months, alright. I had to take a medical exam before I went inside you
know. When I was discharged, the doctor said I had lungs like a 60-year-old man...my medical discharge, for some reason they can't find that,
you know. So I filed a claim for that...I've got emphysema. They said I got it from smoking. They would have never let me in the service if my
lungs was that bad. It was from the lead and asbestos and all the chemical that I was around. But I've been filing for this since '86. I keep
getting the same things. You missed an appointment, so they denied me for that. I just think they want me to give up on it...”
20

IMPORTANCE OF CULTURALCOMPETENCY ANDVALIDATIONOFTHEVETERAN EXPERIENCE
Opinions varied on the level of cultural competency among VA providers, yet veterans noted a stark difference in cultural
competency among VA providers vs. outside the VA in non- veteran-specific care. Some veterans see cultural competency as only
attainable if the provider is in fact a veteran, as they otherwise cannot know and understand fully the experience and background
of the veteran. Some have both the expectation and belief that the VA should and does have culturally informed providers.
“I would say they understand it...as a civilian who has never
been to areas like I've been to or in situations...in a combat
zone or whatever, 'cause...it would be near impossible for
people that have not been there, to imagine it, and I think
there's obviously a great deal of misunderstanding when it
comes down to the military in general. Not every military
person goes through things that I've seen or done things that
I've done...and you know that's what it is. So I guess they
could do the best that they can, and I enjoy that even though
they don't understand it fully, they don't make any
judgments...they're very understanding, I guess, is what's
important.”
“I do think some of them do understand.
Well...honestly, the best example I can think
of, like the psychologist I'm seeing in
psychiatry in the women's groups that I'm
going to...when I explain about the PTSD and
the depression, they definitely do understand
that. Even some that haven't been in the
service, I can tell that they've worked with
other women veterans and they can see...I
think that from the experience they've had
with other patients, it kind of gives me an
idea that they…even though some of them
have not been in the service, they still
understand what women veterans go
through. That part I was actually surprised
about, but that really helped. It lets me know
that I'm not the only patient they've dealt
with, other women veterans, they understand
what they go through because from what the
women veterans tell them about the issues
that they went through in the service... Yeah,
I think that part helps. Even though some of
them may have not been in the service, at
least they can sympathize or understand.”
“The chaplain himself...he's not a medical doctor, but he's
educated himself and his team on that...that they can
recognize symptoms and then make the necessary referrals.
With civilian doctors, they may or may not recognize the
symptoms, and so there's no referrals...there's no further
help, and the person is just turned loose on the street. Not
with those guys, all of them, women and men at the VA, they
understand things in a way about veteran experiences that I
don't think, unless the doctor on the outside is a veteran
themselves, do not understand.”
“The VA doctors...the
ones that I've worked
with...they're not
veterans themselves.
So I know that
they've been trained
on...or given some
kind of special
training to help
veterans, but at the
same time, I don't
know, I just feel like
they don't know what
they're doing, and
can't relate because
they didn't serve.”
21

IMPORTANCE OF CULTURALCOMPETENCY ANDVALIDATIONOFTHEVETERAN EXPERIENCE, cont.
Cultural competency is most important for mental health and less so for primary health, especially primary health issues
unrelated to military service, according to veterans. While veterans interviewed want their primary care provider to coordinate
specialty and mental health care, they tended less to view cultural competency as an important driver for effective coordination
through their care network.
INTERVIEWER: “So speaking of your doctors, have you found
that they understand, that they have any kind of cultural
competency or knowledge about veterans, or is that
something that factors in...”
VETERAN: “Some of them do and some of them don't. It's a
mixed bag.”
INTERVIEWER: “And what do you prefer?”
VETERAN: “Really, I prefer that they just look at me as a
medical patient. They don't have to be particularly looking at
me like, ‘Oh, wow, you're a war veteran or you're this or that.
I mean that's all fine and dandy, but we're just talking about
my body here. I don't want to go in-depth, unless I'm going in
to or it’s a group I'm talking to...as far as other veterans.”
“When it comes to mental health, I think, you
want vet-specific care, but I think the physical
stuff, which is mostly my issues, veteran-specific
doesn't make a difference, I think.”
“I've found, like with the PTSD clinic, and supposedly San
Francisco is the model for the nation, for their treatment of
PTSD, none of them are military. None of them can
comprehend what we are struggling with, sometimes on a
day-to-day basis. I find that there are outside organizations
who have a much better grasp on what we struggle with on
a day-to-day basis, than anyone at the VA does. I've found
some online support who seemed to understand what a
person who's struggling with PTSD is dealing with, much
better than the VA does.”
“If I had a broken arm, I don't care if the doctor
works at the VA or the doctor works somewhere
else as long as they have the experience to treat
whatever needs to be treated. They don't have
to be affiliated with the VA. I go there for their
expertise and their treatment, not for their
affiliation.”
22

RESEARCH HOSPITALS
Given San Francisco VA’s proximity and relationship with University of California, San Francisco, many veterans at the SFVAMC
are receiving care from UCSF’s medical residents. As such, they tend to receive less continuity in those situations. Also of note,
all SFVAMC doctors are also faculty at UCSF which appears to influence veterans’ perceptions of doctors’ experience and
whether veterans believe they are culturally competent.
VETERAN: “Sometimes you can get a little resentment from
doctors that have never had any kind of familiarity as far as
military background...”
INTERVIEWER: “Can you give an example?”
VETERAN: “I've had a couple of really young doctors that
attended me for short periods of time, and the basis of their
doctoring was just, they didn't want to be bothered, it was
just nine to five.”
INTERVIEWER: “What is most important to you about the
care you get at the VA?”
VETERAN: “Most important to me? Seeing a doctor that will
listen to me. I've experienced a couple of interns or others...I
don't know what their position is...if they're doing an
internship...'cause it's a training hospital.… For the young
interns coming out of UCSF, I feel a lot of empathy for them
because they’re dealing with some real difficult people for
many reasons. I wouldn't want the job working there. It's a
difficult environment, and I admire the doctors that do a
good job. There are good doctors there, but it's a hell of a
training ground to hit when you're coming out of UCSF to
get that. I appreciate the care I get, but there is certainly a
two-way mistrust.”
23

Findings: Pre-Conceived Views ofVA Care
EXPECTATION OF POORCARE LEADSTO
CAUTIOUSAPPROACH BYVETERAN
Veterans seem surprised when care quality is superior to
their initial judgment prior to accessing care.
INTERVIEWER: “Initially, when you first enrolled, what was that
process like for you?”
VETERAN: “In Fresno, I was between jobs, so [enrolling at VA]
was a matter of necessity. That said, the VA had a horrible
reputation in Central California for services… and in the 60s and
70s and early 80's, if you needed to go to the doctor in Fresno, in
Central California, you did not go to the VA. If you did not have
the money, then you went to the county hospital as a last resort.
You did not go to the VA.… I did enroll as a last resort, because
of where I was financially, and knowing all of this, there was a
lot of trepidation…. Now, it's a very, very different place.”
INTERVIEWER: “In Fresno?”
VETERAN: “In Fresno. It's a very, very different place. I can't
speak for any of the other places. But in Fresno, it's a very
different place, different atmosphere; they are very welcoming,
very professional.”
“Yeah, you hear so many negative things about the VA and I
went in there and it looked like a really nice hospital. It went well
from the start, so I didn't have any reason to change it, seemed
like.”
WORD OF MOUTHCAN SIGNIFICANTLY HELP
OR HINDER
Word of mouth can significantly help or hinder whether the
veteran enrolls in VA care, and is often the primary basis for
their motives to either enroll or not enroll. Anecdotal
information from VA users, most especially friends and
family members who access the VA, plays a greater role in
motivating the veteran than published reports or even
recommendations from service providers.
Veterans who rate their care experience as high are likely to
recommend the VA to other veterans as well. In addition,
this was especially noted among Swords to Plowshares staff
who are in the likely position of referring veterans to
services.
“I have a really good friend who was recently discharged…. I
said, ‘Dude, carry your butt out to Fort Miley, take your
DD214.... and get signed up with them.’ The next week, I
said, ‘Have you gone out?’...and he was like, ‘Yeah, I already
have my primary care provider.’ He is also seeing a therapist
and psychiatrist down at the downtown clinic, and he's
thrilled with it.”
24

Findings: Pre-Conceived Views ofVA Care
ENROLLMENT DOESN’T HAPPEN NATURALLY
Enrollment typically occurred under specific circumstances for many of the prior-era veterans interviewed, not as an assumed
process during transition out of the military. Most especially it happens when veterans are in crisis. Economic shocks may
sometimes be a contributor, such as when they lose employer insurance, but most often it was as a result of the emergence of
health issues relatable to service. Recently separated veterans, however, appeared more likely to enroll as a product of their
transition and are able to access under the five-year eligibility window of free services post-military.
“I initially signed up a few months
after getting out, 'cause I was trying
to continue my mental healthcare
outside of the Army, and I ended up
signing up for…I guess you get a
certain amount of years of
healthcare because of being in,
either going overseas or being in
combat...I don't know if it's either/or.
So that is how I got started with
getting healthcare in the VA.”
INTERVIEWER: “Did you have any
trouble getting enrolled at the VA?”
VETERAN: “No, I didn't. I actually didn't
enroll in the VA until like about 30 years
after I got out.”
INTERVIEWER: “Oh, wow. And what
prompted you...”
VETERAN: “I was in substance abuse
rehab, and I got referred...I got an
appointment from my counselor with
the VA because I was a veteran, for my
mental health. So I started going to the
VA strictly for mental health.”
“I was ahead of the game when I like
actually got out...I got out on a
Friday, and I enrolled the next
Monday. The VA care providers were
actually kind of shocked that I
enrolled immediately, but my whole
premise for going to VA care is I
didn't have an emergency doctor, or
couldn't get my annual shots, so that
was the whole thing...just getting the
basics covered. So at the time there
was a three-year eligibility window,
so being in college, going into VA
healthcare was the way to go on a
student budget.”
25

Findings: The “Veteran Space”
VETERANS FEEL A CONNECTIONTOVAAS A
“VETERAN SPACE”
Regardless of their patient experience, veterans feel a
certain comfort in getting same care as their veteran
peers, and going to the same place as their veteran peers.
“When I go out to Fort Miley, my comfort level increases
enormously, because all of a sudden, I'm surrounded by a bunch
of other people who are just like me. We might have different
medical issues, different psychological issues, but I understand
and appreciate the Vietnam vets, I understand and appreciate
the Korean War vets, I understand and appreciate what the kids
coming back now are struggling with. So even though I may not
talk to any of the people when I walk into Fort Miley, I feel a
comfort level and a similarity with them that I would not feel,
say walking into St. Mark's or St. Luke's...a non-VA facility.”
“I like the fact that it is VA. I feel much more comfortable in a
setting where everybody else is veterans, and the experience at
the Oakland VA has been very positive. They seem very, very
caring there toward their veterans, and it makes you feel
comfortable.”
“I would say that my health issues are not that extraordinary. I
just feel...I don't know, I guess I'm just more comfortable in the
VA medical care environment. I don't know, the camaraderie or
something. Can you see where I'm coming from with that?”
SENIORVETERANS ANDTHE “VETERAN
SPACE”
Senior veterans feel a particular comfort and connection to
the veteran space. Among older veterans interviewed, the
veteran space fosters a tangibility to their memories of
military service and a connection where they might
otherwise feel increasing social isolation through the aging
process.
“In the VA, if you get there early, you sit down in the lobby…you
relax. And you hear the chit chat.”
26

Conclusions & Recommendations
ENSUREVA PROVIDERS CAN COORDINATECARE
Veterans observe when their care is easily coordinated and essential services are integrated in a seamless manner. Conversely,
veterans feel underserved when their care is not managed effectively. Treatment of distinctively military disabilities is dependent
on a multitude of factors, including close communication and coordination among providers. Among VA users, 25 percent of the
primary care patient population have comorbid chronic mental illness, and mental health providers have been able to diagnose,
otherwise unseen by primary care, illnesses which necessitate a coordinated response which engages both primary and mental
health in the delivery of veteran healthcare. Studies show veterans who screen positive for mental health issues are more likely to
begin treatment if they see a mental health professional the same day that they are diagnosed. Medical conditions as a result of
military service are complex, require a unique approach, and necessitate multiple care competencies. As the number of Priority
1A users are expected to double in the next 20 years, primary care doctors need to engage and work closely with specialists and
mental health as a vital means of maintaining an integrated model.
ENSURE CASE MANAGEMENT, CONTINUITYAND CONSISTENCY IN PROVIDERS, ESPECIALLY FOR
THOSEWITH CRITICAL NEEDS
Veterans want continuity in their care, even when their doctors change. They don’t want to navigate new relationships with
multiple providers, and when there is staff turnover, they want their new providers to do their homework and ensure their
healthcare needs are understood and their care approach is similar to their previous provider.
Those who express favorable provider relationships tended to have the same doctor for a longer period of time. The VA needs to
invest resources to retain highly qualified, and highly regarded providers.
For veterans with critical needs, intensive case management is crucial for their improvement and increased health outcomes. The
almost 250,000 veterans with serious mental illness seen at the VA need increased coordination among their care team, and
consistency throughout their care plan.
Mental Health Intensive Community Recovery Services, VHA Handbook 1163.06 (2016).
27

INCREASE ACCESSTO MENTAL HEALTHCARE
While group therapy is becoming increasingly common and is cited to increase access, decrease costs, and allow veterans to
identify with others, it may not serve the needs of all veterans. While veterans cite the benefits of longer-term therapy than they
experience in the private sector and the importance of evidence-based practices which incorporate a trauma and culturally
informed care approach, it’s clear they need mental health services tailored to their individual needs. Treatment for PTSD, a
hallmark of the VA mental healthcare model, should not be reduced to group therapy due to demand or cost restrictions. Its clear
veterans want this service from the VA, who have shown in previous studies to have a higher evidence-based practice than non-
VA and non-military providers.
COMMUNICATETOVETERANS ABOUT CHOICE PROGRAMANDVA CAPACITY,AND PRESERVEVA’S
ROLE AS COORDINATOROF CARE
While a primary motive of the Choice program is to expand options for veterans with limited access to needed services, some
veterans feel very strongly that Choice will restrict their access to services at the VA even further. While some veterans expressed
timeliness as the primary reason why they would utilize the Choice program, perhaps the most telling of the data is among those
who access services from the San Francisco VA Medical Center, wherein a significant number of specialty services are available,
veterans are less apt to seek care through Choice even if it means they won’t have to wait.
Recommendations for expanding the Choice program should include VA as a coordinator of care and referrals, and ensure VA
providers are communicating thoroughly with veterans regarding substantial changes in their care due to Choice. VA providers
need to be the navigators for this care. Opportunities for expanding needed resources at VA centers where veterans are seeking
Choice due to limited services should be examined, even when Choice is favorable due to local circumstances, as veterans
interviewed tend to feel strongly that if the service is offered at their VA, that’s where they choose to seek it.
RAND, 2014
28

VALIDATIONAND REALTALK
Veterans feel supported when their providers are acting on their behalf. They feel a particular resentment when they need to advocate for
their care or feel judged by their military experience and burdened by having to establish proof of their service-connected injuries. Patient
advocates have been a great resource for veterans to seek validation and gain an ally in their healthcare advocacy, but providers themselves
need to act as advocates with a veteran-centered approach to care. This is especially true for veterans whose personal accounts of service
may not correlate with military records.
Veterans need real talk about their care experience, and want to be more informed consumers. Customizing communications and offering
online, app, telephone, and direct mail communications tailored according to the best mode for the veteran allows them to feel more
informed about their healthcare choices and outcomes. In addition, VA outreach campaigns which include personal accounts from veterans
voicing their positive, and even challenging, experiences could significantly help the VAs reach more veterans.
HIRE MOREVETERANS AND INCREASE ACCESSTO PATIENT ADVOCATESAND PEER MENTORS
Establishing hiring practices which recruit veterans into jobs at the VA will expand a peer-based model and increase confidence among
veteran patients that the VA can take care of their needs. Patient advocates have proven effective at supporting veteran healthcare and
informing veterans of their healthcare choices. The VA is the largest employer of peer mentors in the world. Veterans should have easy access
to patient advocates and peer mentors to improve engagement in treatment and self-advocacy in treatment, which studies show it has
proven to do.
29
“VA Research Currents: Better Preparation, Planning Could Improve Effectiveness of VA Peer Specialists,” U.S. Department of Veterans Affairs, Office of Research & Development, accessed
February 4, 2016, http://www.research.va.gov/currents/winter2015/winter2015-26.cfm.
“VA Research Currents: Better Preparation, Planning Could Improve Effectiveness of VA Peer Specialists,” Matthew Chinman, March 19, 2015, accessed February 4, 2016,
http://www.research.va.gov/currents/winter2015/winter2015-26.cfm.

INCREASE CULTURAL COMPETENCYTRAININGS FORVA PROVIDERS
Cultural competency is an expressed need among almost all who were interviewed, and many Veterans assume that providers in veteran-
specific care have this knowledge. When they receive care from providers without an understanding of veteran culture, values, and
healthcare needs, it can lead to tremendous distrust between the provider and patient.
Ensuring providers across medical centers meet minimum requirements for cultural competency training in addition to medical specialty
training will ensure veterans are receiving culturally informed care and will benefit the provider and veteran relationship. Given 70 percent of
all U.S. doctors receive training at VA medical centers, establishing provider networks with non-VA providers who have received both medical
specialty training and cultural competency is recommended.
MOVETOWARDVETERAN-FOCUSED,ANDVETERAN-CENTRIC CARE
Veterans have a real sense of the national VA care conversation, and feel a considerable disconnect from determining their own healthcare
outcomes. When decisions are made without veteran input, veterans either feel very strongly that they must become their own advocate and
fight for their care, or become disenchanted by the process and consequently don’t receive the care they need, leading to illness burden and
poorer health outcomes. Ensuring veterans are part of the decision-making process will move toward a veteran-centric approach to making
the necessary improvements to VA care.
“We're all going to need healthcare, and good healthcare, forever. It's something that's a must. They need to
unload a lot of the riffraff and bureaucratic crap and get to the meat of helping the VETERANS. And you've got a
lot them that get so frustrated so easily because they don't have the strength to fight for themselves. A lot of
times, their families don't have the strength to fight for them either, and that is so sad. I know I've run into that
in all kinds of communities.”
30

Copyright © 2016 by Swords to Plowshares
All rights reserved, including the right of
reproduction in whole or in part in any form.
Swords to Plowshares
Institute forVeteran Policy
1060 Howard Street
San Francisco, CA 94103
Megan Zottarelli
Senior PolicyAnalyst
mzottarelli@stp-sf.org
Amy Fairweather
Director
afairweather@stp-sf.org

Right to Care: Voices of Swords to Plowshares' Veteran Community

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