November 16, 2011 |  5:56 pm

November 7, 2011 • Terry Howell

Read more:
http://militaryadvantage.military.com/2011/11/plans-to-take-tricare-prime-from-retirees/#ixzz1d8DF0Uux

Do I have to cancel employer’s policy to use Tricare for Life?

December 9th, 2011 | TriCare Help | Posted by Military Times

I will turn 65 later this year and become eligible for Medicare and Tricare for Life. I have another health insurance policy through my employer. I’ve heard that I have to cancel the other policy to use Tricare for Life, but my wife and children still need that coverage. I asked and was told that I can’t cancel just my own coverage and leave my family insured under my employer’s plan. What can I do?

You were misinformed. You do not need to cancel your other health insurance policy to qualify for Tricare for Life. The legal requirement regarding other health insurance is that Tricare must always be last payer to all other coverage, except welfare-related plans such as Medicaid.

When Tricare beneficiaries become entitled to Medicare and are enrolled in Part B, they are covered under Tricare for Life. If they have no other health insurance, Tricare Standard acts as a free Medicare supplement and last payer to Medicare.

After it processes a claim and makes whatever payment is due, Medicare automatically transfers the claim to Tricare electronically. In the vast majority of claims, Tricare pays whatever Medicare did not pay for Tricare-covered services — usually the beneficiary’s Medicare deductible and co-payment.

Your situation will be different because of your other health insurance. As you read the following, keep in mind that Tricare must always be last payer to all your other coverage, regardless of which plan is first or second payer.

Let me summarize the situation regarding your family:

Tricare for Life rules do not require you to cancel or alter your employer’s health insurance policy. You and your family may continue coverage under your employer’s plan. Regardless of decisions you make about your Medicare coverage, your family’s Tricare coverage as second payer to your employer’s plan will not be affected.

Now, the following pertains to you only, not your family:

When you become entitled to Medicare, you will be told that Medicare does not require you to enroll in Part B as long as you continue to work for the employer that provides the other health insurance. Also, for as long as you continue to work for that employer, your employer’s plan will be your primary coverage. Medicare will be second payer.

Although Medicare’s rules allow you to postpone Part B enrollment for as long as you continue to work, Tricare’s rules do not allow that.

According to law, retirees or their family members who become entitled to Medicare must enroll in Part B of Medicare in order to retain Tricare eligibility.

If you feel that Medicare Part A plus your employer’s plan is enough health insurance for you (yourself only) while you continue to work, you might want to postpone Part B enrollment during that period. That will allow you to avoid paying the monthly premium for Part B. But you will be ineligible for Tricare for Life until you enroll in Part B.

That’s a decision only you can make. Before you do, I suggest you contact Medicare for details about the kinds of health care services Part A covers.

You’ll want to enroll in Part B, however, as soon as you stop working. Your Tricare eligibility will be restored as soon as you do that and your Defense Enrollment Eligibility Reporting System (DEERS) record has been updated.

For as long as you continue to work, you must file claims with your employer’s plan first. Medicare Part A will be second payer to that plan. You will no longer have Tricare as a last-payer backup because you are not enrolled in Medicare Part B.

When you are no longer working, you will file claims with Medicare first. Your employer’s plan will be second payer to Medicare. If you have enrolled in Part B, Tricare will be last payer to your other coverage.

Depending on the extent of the other plan’s coverage, it will very likely pay what Medicare does not pay in much the same way that Tricare would. After Medicare and the other plan have both completed processing and you have the explanations of benefits from both, you may file a claim with Tricare for any amounts they left unpaid.

As I said earlier, regardless of decisions you make, your family members will continue to have your employer’s plan as their primary coverage and Tricare as second payer on their claims. Their Tricare coverage will not be affected by your Medicare entitlement or the decision you make about Part B enrollment.

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Upon becoming disabled and the decision to sign up for social security benefits, information arrives in the mail about Medicare.  Hopefully you’ve read all the information sent.  Nowhere in the information does it state that if you accept Medicare what effect it may have on your current health insurance if in fact you have other health insurance.  DO YOUR HOME WORK!

Becoming Medicare Eligible - TriCare

Medicare is a health insurance program for people:

• age 65 or older
• under age 65 with certain disabilities
• with end stage renal disease
• with Lou Gehrig's disease

Medicare Part A is premium-free hospital insurance.  Medicare Part B is medical insurance, and you must pay Medicare Part B premiums to keep Medicare Part B coverage.  The Centers for Medicare & Medicaid Services manages Medicare.

Medicare and TRICARE
TRICARE beneficiaries who have Medicare Part A, must have Medicare Part B to remain TRICARE-eligible. The only exceptions are if:

• Your sponsor is on active duty
• You're enrolled in the US Family Health Plan
• You're enrolled in TRICARE Reserve Select

If you fall into one of these categories, you are not required to have Medicare Part B to remain eligible for TRICARE. However, we strongly encourage you to get Medicare Part B as soon as you become eligible for Medicare Part A to avoid any future loss of TRICARE coverage. For specific details about your Medicare-eligibility requirements, please enter your profile.

• Learn more about Medicare eligibility and TRICARE
• Learn more from Social Security

Forced Into Medicare - MARCH 24, 2011

A federal judge tells seniors to take it or lose Social Security.

This week marks the first anniversary of ObamaCare, and if you are wondering where that coercive law is headed, we'd point to a case in federal court. That's where Judge Rosemary Collyer has ruled that Americans have a legal obligation to accept sub par government health benefits.

It remains a remarkable fact that America obliges most citizens over the age of 65 to take that rickety government health plan known as Medicare. Judging by today's growing number of health-savings options (HSAs, medical FSAs), some Americans would prefer to maintain private coverage upon retirement, rather than be compelled into second-rate Medicare. (To read more log in to The Wall Street Journal online).

The above article applies to civilians, per my conversation with TriCare Eligibility on 06/13/2011.  However, once you've seen the title and subtitle you probably cringed.  Nonetheless, even if that ruling was meant for only civilians, why/what/who would make such an obnoxious law?  If the civilians maintain their own insurance, why should they be forced to take Medicare when their insurance most likely pays much better?

Once a veteran is receiving social security disability, they are then “eligible” for Medicare.    Upon the 25^th month of receiving SSD (Social Security Disability) payments, the SSA (Social Security Administration) will automatically sign you up for Medicare Part A and offer you Medicare Part B without your knowledge.  Medicare Part A is hospitalization payments and is free to the disabled.  Just so you know, Part A just means you can have a bed at the hospital.  It doesn't cover anything else.  Medicare Part B pays for outpatient healthcare and doctors’ fees.  The Veteran does not have a choice to accept or deny Medicare.  Once you are eligible the SSA reports this information to the DoD (Department of Defense) and TriCare.  TriCare then sends you a letter that your benefits are about to change.  The Veteran is then required to purchase Medicare Part B at the rate of $115 per month or TriCare will not pay any claims or provide you with further coverage if Medicare Part B is not taken.  This means the Veteran lose all TriCare benefits.  However, the Veteran is still eligible to seek health care with the VA, but this does not apply to the Veteran’s beneficiaries.  If the Veteran has beneficiaries (spouse and/or children), they too lose all TriCare benefit coverage.

(Click to read documents)

You Can't Opt Out of Medicare without Losing Social Security, Judge Rules

Elder Law Answers Last Updated: 3/22/2011 12:01:30 PM

Retirees cannot dis-enroll from Medicare Part A without also losing their Social Security benefits and refunding all the money paid to them, a federal judge has ruled.

The judge dismissed a case, Hall v. Sebelius, brought by three retired federal employees who have reached age 65 and are receiving Social Security Retirement benefits, but who would like to drop their Medicare Part A coverage, which pays for care in institutions like hospitals.

Anyone who has reached age 65 and who is entitled to Social Security benefits is also automatically entitled to Medicare Part A without charge. However, the three plaintiffs, one of whom is former Republican House Majority Leader Dick Armey, wanted to drop their Medicare coverage because they claimed it threatened their coverage under the Federal Employees Health Benefit (FEHB) program, which they said was superior. They argued that the Medicare law allows them to drop out of the program without losing their Social Security benefits.

In her March 16, 2011, ruling, Judge Rosemary Collyer of the U.S. District for the District of Columbia acknowledged that the three retirees had a legitimate point that the law does not specifically say that avoiding Medicare Part A means losing Social Security benefits. But in examining the law that Congress enacted in 1965 creating the Medicare program, Judge Collyer found that "[requiring] a mechanism for Plaintiffs and others in their situation to 'disenroll' would be contrary to congressional intent, which was to provide 'mandatory' benefits under Medicare Part A for those receiving Social Security Retirement benefits." [emphasis in original]

The judge also pointed out that the plaintiffs would not gain much by renouncing their Medicare coverage. Even if they were to fore go and repay all Social Security benefits, under the law "their FEHB-paid benefits would be no more, and no less, than what Medicare Part A would provide," Collyer wrote.

The ruling could have implications for the current court cases challenging the new health reform law. A central basis of these challenges is that the "individual mandate," the reform law's requirement that all Americans have health coverage, is illegal because the government can't compel citizens into economic activity. Judge Collyer's ruling suggests that the government may already have been doing this in the area of health care for the past 46 years. Indeed, the Washington Times notes in an editorial that on February 22, "D.C. federal district Judge Gladys Kessler cited preliminary rulings in Hall v. Sebelius to conclude that the [individual] mandate is allowable."

The plaintiffs plan to appeal the decision.

To read the court's decision, click here.

Medicare Part D Prescription Drug coverage Creditable Coverage

Veterans Administration Retrieved 6/10/11

If the Veteran is eligible for Medicare Part D prescription drug coverage, you need to know that the enrollment in the VA health care system is considered creditable coverage for Medicare Part D purposes.  This means that VA prescription drug coverage is at least as good at the Medicare Part D coverage.  Since only Veteran may .enroll in the VA health care system, dependents and family members do not receive credible coverage under the Veteran’s enrollment. 

However, there is one significant area in which AV health care is NOT creditable coverage:  Medicare Part B (outpatient healthcare, including doctors’ fees).  Creditable coverage for Medicare Part B can only be provided through an employer.  As a result, VA health care benefits to Veterans are not creditable coverage for the Part B program.  So although a Veteran may avoid the late enrollment penalty for Medicare Part D by citing VA health care enrollment, that enrollment would not help the Veteran avoid the late enrollment penalty for Part B.

VA does not recommend that Veterans cancel or decline coverage in Medicare (or other health care or insurance programs) solely because they are enrolled in VA health care.  Unlike Medicare, which offers the same benefits for all enrollees, VA assigns enrollees to priority levels, based on a variety of eligibility factors, such as service-connection and income.  There is no guarantee that in subsequent years Congress will appropriate sufficient medical care funds for VA to provide care for all enrollment priority groups.  This could leave Veterans, especially those enrolled in one of the lower-priority groups, with no access to VA health care coverage.  For this reason, having a secondary source of coverage may be in a Veterans’ best interest. 

In addition, a Veteran may want to consider the flexibility afforded by enrolling both VA and Medicare.  For example, Veterans enrolled in both programs would have access to non-VA physicians (under Medicare Part A or Part B) or may obtain prescription drugs that are not on the VA formulary if prescribed by non-VA physicians and filled at their local retail pharmacies (under Medicare Part D).

Additional information on Medicare Part D prescription drug coverage can be found online at http://www.va.gov/healtheligibility/costs/MedicareDEligibility.asp or health and Human Service Medicare website at www.medicare.gov. 

Per my conversation with TriCare Eligibility on 06/13/2011, if the disabled person who is on SSD has TriCare and uses ExpressScripts, your prescription coverage will remain unaffected.

It is important to note that VA health care in NOT considered a health insurance plan.

Unfortunately, I found out the hard way by being disabled and a retired, service-connected disabled Veteran’s wife.  I am in the same boat as thousands of disabled Veterans and their families.  Because I have been determined by the SSA to be disabled, I am forced to pay for health coverage that I am otherwise entitled to  by being married to a service-connected disabled veteran. This is not a political soap box, merely a lightning bolt to cause unsuspecting disabled Veterans to see what’s in the future. 

What will you do?  How will you react when your life is turned upside down and ordered by the government to pay for something you don’t want. Then to have had the well deserved and earned benefits of a service member take a backseat to government required sub par healthcare that you need to pay for?  

Per my conversation with TriCare Eligibility on 06/13/2011,TriCare's stance and rules regarding Medicare with TriCare has been in effect for many years.  The bill was written and has been sitting on a desk just waiting to be passed.  The only coincidence is that the bill was signed into legislation during Obama's term.  So if you want to blame someone for this issue, blame TriCare.  The president just inked the deal.

(The opinions expressed here are not those of the organizations, people or companies in this commentary)

Multimedia

• 
  For service members, vets, families, and providers, this DVBIC PSA features Commander Hancock, MD who shares his perspective as a shock trauma platoon doctor and a person with a TBI.
• Healing After a Military TBI: A Doctor/Patient Perspective
• 
  Living with a TBI can be life long; with work, improvement never ends.
• Recovering from at TBI: A Marathon, Not a Race
• 
  Post-deployment syndrome can include concussion, PTSD, major depression, chronic pain, and general anxiety disorder.
• What Is Post-Deployment Syndrome?
• 
  Not knowing the root of medical and psychological problems often exacerbates the issues; a clear diagnosis is important for successful recovery.
• Post-Deployment Syndrome Versus Multiple Syndromes
• 
  Clinicians need to define a methodical framework of recovery for people with post-deployment syndrome.
• Where to Begin After Being Diagnosed with Post-Deployment Syndrome
• 
  A neuropsych evaluation after a brain injury covers wide ground from visual deficits to memory problems.
• Testing Memory, Attention, Behavior, and Much More
• 
  Military experts are working to define what baseline testing for TBI would be most effective for pre- and post-deployment comparison, as well as for use in theater.
• Building an Effective Military Baseline Test Platform for Brain Injury
• 
  Soldiers who have sustained three concussions will receive a more detailed, mandatory evaluation before returning to combat.
• New Military Protocol Emphasizes "Better Safe than Sorry"
• 
  Dr. Maria Mouratidis is is a licensed neuropsychologist and currently the command consultant and subject matter expert for Traumatic Brain Injury and Psychological Health at the National Naval Medical Center. This is BrainLine's exclusive interview with Dr. Mouratidis recorded on September 17th, 2008. Transcript of the video here.
• Dr. Maria Mouratidis Talks About Military Families and Brain Injury

It’s not just fun and games; learn what vets and service members are doing at Walter Reed’s Brain Fitness Center.

To an outsider it might just look like fun and games, but at the Brain Fitness Center on the campus of Walter Reed Army Medical Center in Washington, DC, war veterans and service members are using high-tech programs to help their brains heal.

The Brain Fitness Center (BFC) at Walter Reed Army Medical Center (WRAMC) opened in 2009. The BFC’s goal is to give active duty and veteran service members with cognitive dysfunction — that is, difficulty with attention, memory, decision-making, etc. — the opportunity to explore brain-fitness products and perhaps find something new, challenging, and engaging to help in their rehabilitation. The cognitive workout patients receive in the BFC does not replace traditional rehabilitative therapies, but many feel it enhances their recovery.

Over the last decade or so, research has proven that — contrary to years of believing differently — the brain can continue to learn and become stronger at any age. In addition to eating right, staying social, reducing stress, getting sound sleep, and participating in physical exercise, exercising the brain is one of the top ingredients to a healthy body and mind.

Thanks to advances in our understanding of neuroplasticity — that is, the brain’s ability to change itself — as well as demand from the aging Baby Boomer generation, brain training programs have proliferated and become widely available. “Brain gyms” are popping up around the country with products to help you “think younger.” Fun and affordable online games and smartphone apps are also now widespread.

Although originally designed for people as they age, these brain-stimulating products can also help people who have sustained a traumatic brain injury (TBI).

“Think sharper”

There are a variety of ways to maintain brain health, including staying socially active and physically fit, and choosing “brain foods” (eat more berries and salmon!). Just as physical exercise is necessary for physical fitness, brain exercise is important for maintaining brain fitness. The most important aspect of brain exercise is doing something novel and challenging — something that offers a variety of stimuli. At any age, taking up knitting, a foreign language, or a musical instrument will challenge your brain. Once you’ve mastered one skill, you should find a new one to try so that your brain is challenged with new stimuli. The benefit of computer-based products is that computers can generate thousands of different stimuli in a short time-frame and in an entertaining, game-like format.

Most brain training programs assess a person’s level of cognitive function and provide exercises at an appropriately challenging level. Brain exercises should not be frustrating; however, they should be challenging. Like physical exercise, if you push yourself a little more each time you work out, you receive increasing benefits.

As most people know from exercising, finding a sport or routine that you like is important. If you don’t like swimming laps, playing tennis, or lifting weights, you probably won’t stick with it. By the same token, it’s important to find a brain-fitness product that fits your lifestyle demands and personal needs. There are brain games, more clinically focused brain exercises, and then there is focused brain training for a specific cognitive function or group of functions. Some products are designed to cross-train multiple areas and others target one specific area. For example, some programs may provide exercises for your memory, attention, and language skills while others to target a specific area like visual processing. The research on the effectiveness of these products varies, but currently, the jury is still out on how useful these products are for recovery from TBI. However, new research is addressing the direct and indirect benefits of some of these programs for patients with TBI and post-traumatic stress disorder (PTSD).

With the variety of brain training products on the market, it can be daunting for someone with a brain injury to sort through and evaluate each product to find what works best. It’s great to have choices, but you need to do your homework. Many of these products are expensive and may require a subscription with additional payments. The Brain Fitness Center at WRAMC offers a library of products for test driving and for regular use. The goal is to make tools for good brain health easily accessible. The BFC offers computer programs that can be used in the center by appointment, software that can be taken home, web-based technology, and brain games for hand-held devices. This way, you get to try them out and find the ones that best fit your needs and preferences.

Brain training products can vary from free iPhone apps to $400 software programs. The BFC works closely with the American Red Cross chapter at Walter Reed to provide software to service members through donations. If you are an active-duty service member or veteran and you want to purchase a product but the cost is too high, contact your local VA or Military Treatment Facility (MTF) to see if there is a Red Cross or other charitable organization able to provide these items. Many groups raise money for items such as smartphones, laptops, and assistive devices, and these groups may be able to include brain training software as part of their donations. These groups may be especially helpful for people who live in rural areas or for those who cannot get to the BFC.

What’s out there?

The products and resources listed below are used in the Brain Fitness Center at WRAMC, although there are other excellent programs on the market. Please note that Walter Reed, the Department of the Army, and the Department of Defense do not endorse these or any other specific products.

• Brain Fitness Classic by Posit Science: This product aims to sharpen auditory processing skills. Increasing the speed and accuracy of information you hear has been shown to make you “think quicker” and improve certain aspects of memory. PositScience recommends that you use this product daily for 60 minutes over an eight-week period. Brain Fitness Classic is available on CD for your home computer (Mac or PC).
  http://www.positscience.com/our-products/brain-fitness-program

• Dakim BrainFitness: Dakim uses a cross-training model, with exercises in memory, visual processing, critical thinking, language, and calculation. The stimuli are varied and include video clips of movies, famous songs as well as trivia. This program is designed to be used over the long term and to provide continuously novel content. Dakim recommends using the program 20 minutes a day at least two to three times a week. Dakim BrainFitness is available on CD for your home computer (Mac or PC).
  http://www.dakim.com/

• Insight by Posit Science: This program is designed to increase the accuracy and efficiency of visual information processing. Reacting more quickly to visual stimuli and expanding the visual field are two goals of the program. Many of the exercises in the program are part of their driving-safety software, designed to reduce the risk of accidents. Posit Science recommends that you use this product daily for 60 minutes over an eight-week period. Insight is available on CD for your home computer (Mac or PC).
  http://www.positscience.com/our-products/insight

• Lumosity: Lumos Lab’s website provides exercises targeting memory, attention, speed, flexibility, and problem solving. Users can design their own personalized training, including “courses” with TBI- and/or PTSD-specific content. Users have some control over what exercise they select on given day, and the content adapts to the appropriate challenge level. Lumosity is available on the web and as an iPhone app.
  http://www.lumosity.com/
• Nintendo Brain Age I and II: These two products are specifically designed for the Nintendo DS, a hand-held game device. The initial assessment tests your “brain age,” which could be “70 years old” even if you are only 27. From there, you work to decrease your brain age with exercises. The program has familiar games such as Sudoku, and the difficulty adjusts for the user. Two different Nintendo DS owners can compete in games. Brain Age is only available for the Nintendo DS.
  http://www.brainage.com/

• Sharpbrains.com provides a useful checklist to use when evaluating if a brain-fitness product is right for you. http://www.sharpbrains.com/resources/10-question-evaluation-checklist/

Brain games don’t replace traditional rehab

The staff at the BFC is part of WRAMC’s traumatic brain injury rehabilitation team and works to accommodate each person’s unique needs. The BFC does not replace traditional cognitive therapy. If a person is currently in, or has been recently discharged from, speech or occupational therapy, BFC staff works with that person’s therapist to best help him with his rehabilitation goals.

If you suspect an undiagnosed cognitive dysfunction and have not been evaluated by a neuropsychologist, speech or occupational therapist, you should first seek out an appropriate evaluation. If you do not have a specific diagnosis of TBI or have already been through TBIrehabilitation and are looking for ways to improve your overall brain health, a commercially available product may be worth exploring. Take some time to peruse the websites of the companies that have developed these brain products. Look for free demos and promotions. Try to get a good grasp on the time commitment recommended and the targeted areas of improvement. Just like working out at the gym, maintenance is important. If you use a program intensely for a few months, it is likely you will notice some benefits, and conversely, if you stop using the program, your benefit will decrease over time. Continuing with a program — for brain and body — provides long-term benefits. So consider whether the program will become boring or too time-consuming. Pick something that fits your needs and is something that will be engaging in the long term.

Studies not only show that maintaining a healthy brain can help reduce the risk for dementia,¹ but some brain training products also show evidence of improving overall quality of life.² However, since most studies for these products have been conducted with the aging population, the Brain Fitness Center at Walter Reed hopes to help provide outcomes for its unique population. The center is committed to investigating the effectiveness of these products by collecting data that may shed light on subjective and objective changes after the use of these products. We have seen more than 130 patients in the last year-and-a-half. A retrospective analysis of those first 100 patients is underway, and staff is currently recruiting for a randomized-controlled prospective research study comparing two of the products. The BFC was recently awarded a government grant for a multi-site randomized study to examine the effectiveness of a new product.

Sound mind in sound body

Cognitive exercise is only one factor in brain health. Our brains benefit from overall physical and mental health. So eat well, sleep and exercise more, find ways to reduce the stress in your life, and maintain your social relationships.

About the author

Kate Sullivan M.S., CCC-SLP, CBIS completed her undergraduate and graduate degrees in Communication Sciences and Disorders at James Madison University. She has been a speech-language pathologist at Walter Reed Army Medical Center for 10 years where she recently helped launch the Brain Fitness Center (BFC), located in the WRAMC’s Military Advanced Training Center, to complement traditional care approaches.

The views expressed in this presentation are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or U. S. Government.

Sources

1. Wilson, R. S., Scherr, P. A., Schneider, J. A., Tang, Y., Bennett, D. A. (2007). Relation of cognitive activity to risk of developing Alzheimer's disease. Neurology 69(20):1911-20.
2. Smith GE, Housen P, Yaffe K, Ruff R, Kennison RF, Mahncke HW, Zelinski EM. A cognitive training program based on principles of brain plasticity: results from the improvement in memory with plasticity-based adaptive cognitive training (IMPACT) study. J Am Geriatr Soc 2009 Apr;57(4):594-603.

Written exclusively for BrainLine by Katherine Sullivan, MS, CCC-SLP, CBIS, Brain Fitness Center, Walter Reed Army Medical Center. www.wramc.amedd.army.mil.

Berkshire Eagle May 22, 2011

They've fought battles in faraway lands; they've saved lives under a hail of gunfire and shrapnel. And now, after months or years abroad, they've finally come home.

The repetitive stutter of a machine gun, shocking boom of mortars, the deafening drone of helicopter rotors; the sounds of war are hard to ignore and can leave many Veterans with permanent hearing damage.

Tinnitus is the number one disability among Veterans and it affects at least one in every 10 American adults.

Some describe ringing sounds, a buzzing sound, a high-pitched whistle, or numerous other sounds. The causes and effects of tinnitus vary from individual to individual, so researchers at the National Center for Rehabilitative Auditory Research approached treatment options the same way.

“Because tinnitus has many causes, many of which are outside the audiology scope of practice, the approach to tinnitus should be interdisciplinary,” explained Dr. Paula Meyers, Audiology Section Chief at the Tampa VA Hospital.

“Some of these services are performed by audiologists and some are referred to appropriate professionals. The goal is not to silence tinnitus, because there is no cure. Rather, the goal is for patients to learn to self-manage their reactions to the tinnitus.”

Dr. Meyers is a member of the VA research team that developed the Progressive Tinnitus Management (PTM) approach. The culmination of years of studies and clinical trials, PTM evolved into a national management protocol for VA medical centers.

The model is designed to address the needs of all patients who complain about tinnitus, while efficiently utilizing clinical resources. There are five hierarchical levels of management: (1) Triage, (2) Audiologic Evaluation, (3) Group Education, (4) Interdisciplinary Evaluation, and (5) Individualized Support. Throughout the process, patients work with a team of clinicians to create a personalized action plan that will help manage their reactions to tinnitus and make it less of a problem.

“A lot can be done for tinnitus”

“Patients have often been told to go home and learn to live with it, nothing can be done — and it’s really not true. A lot can be done for tinnitus,” said Dr. James Henry, PTM author and Research Professor in Otolaryngology at the Oregon Health & Science University.

Educating patients and providers is a significant element in the PTM approach. For health care providers, the authors of PTM organized a triage procedure to help identify tinnitus patients and access exactly what kind of medical services will best serve their needs. Typically, audiologists coordinate all tinnitus care.

“That’s our front line, when they come in for the hearing test,” said Dr. Cheri Ribbe, audiologist at the Boston VA Healthcare System where they started using PTM over two years ago. Her audiology clinic has seen over 500 Veterans take part in PTM — some who just came in for more information, and some who have gone on to higher levels of the PTM program.

The majority of people with tinnitus, about 80 percent, are not bothered by it; it doesn’t affect their sleep or their ability to concentrate. The small percentage of people who struggle with the noise in their head can be more prone to other debilitating mental health problems, like depression and anxiety. It is not yet understood why tinnitus affects people so differently.

After years of having few resources to offer tinnitus patients, Dr. Ribbe said she was excited to institute the PTM protocol. “It’s been gratifying and satisfying for us and the patient to know that we are offering something for them.”

Sound Therapy

Once referred into the program, all patients with tinnitus are given a hearing exam. During the exam audiologists counsel patients regarding hearing loss, tinnitus and provide Veterans with educational materials.

Patients that need more guidance in finding a way to live with tinnitus are referred to group education workshops. Five sessions teach both audiologic and cognitive behavioral coping techniques.

Veterans are given a comprehensive self-help workbook with supporting materials, like worksheets and audio samples. Dr. Meyers explained that instructors have the flexibility of using the provided handouts, slides, sound demonstration CDs, and DVDs to teach the workshops. She also noticed that group dynamics played an important role in the learning process.

“Patients love to talk about their tinnitus,” she said. “Which, as an audiologist, is what you don’t want your patient to do. You want to get their mind off the tinnitus. But in a group session, an audiologist is there to guide them through the process of how to manage their reactions to tinnitus.”

The use of sound is an important component of therapy for tinnitus. The self-help workbook offers many sample sounds and patient examples that Veterans can try out. They are taught to test three different sound management techniques: “soothing sounds” that offer relief from the stress they feel from tinnitus; “background sounds” that lessen awareness of the tinnitus; and “interesting sounds” that shift their focus away from the tinnitus.

Following up with management technique results in class has given the instructors a better understanding of the highly-individualized symptom they are trying to manage.

“The idea is to let them be open to sounds that they never would have even thought of,” explained Dr. Ribbe. She said that she never would have considered traffic noise as sound therapy, but for one Veteran who had grown up in the city those sounds brought him back to his childhood and pleasant memories.

Coping techniques

Another technique covered in the workbook and class is cognitive behavioral therapy (CBT) exercises that address the negative reactions tinnitus can trigger.

“A lot of people with tinnitus develop emotional reactions to tinnitus,” said Dr. Caroline Schmidt, PTM author and Licensed Research Psychologist at the VA Connecticut Healthcare System. “Those could be lack of sleep, feeling anxious, frustration; some people relate the sound to a particularly traumatic event that happened.”

Whether the Veteran is already in contact with a mental health specialist or not, the PTM program introduces them to a series of CBT exercises that have proven effective in helping many tinnitus patients. Relaxation techniques, distraction by planning pleasant activities and changing how patients think about tinnitus are the three main techniques taught in the class.

After completing the workshops, many Veterans are able to come up with an action plan to manage their tinnitus through audiologic, cognitive behavioral techniques or some combination of the two. Providers follow up six weeks later to check on their progress and set up additional assistance for the few patients who need it.

In individual sessions, Dr. Schmidt said, “We review what we did with them during the classes. We review their individual response to those coping skills and help them really focus on problem solving those issues.”

National protocol

In 2010, every VA medical facility audiology clinic received copies of the PTM clinical handbook, counseling guide and hundreds of patient-education workbooks.

The number of Veterans that complete the group education stage of PTM and go on to need individualized support is very small. So PTM’s hierarchical approach provides VA medical facilities with the most efficient means to educate Veterans and teach them self-management techniques.

“We’re always evolving, so PTM is not a static program,” said Dr. Henry. The patient-education workbook is already in its third edition and Dr. Henry has more clinical studies underway to expand PTM’s availability and effectiveness.

“We can’t cure it and nobody can cure it, so the next best thing is to learn self management techniques.”

Related links:
  National Center for Rehabilitative Auditory Research
  VA National Center for Rehabilitative Auditory Research

Psychosocial Rehabilitation and Recovery Center

For a Veteran with serious mental illness, the idea of living a more fulfilling life and developing their full potential can sometimes seem insurmountable.

There is an exceptional program in the VA that is making it possible.

It’s called the Psychosocial Rehabilitation and Recovery Center (PRRC).

Veterans in the program, like the one at the San Francisco VA Medical Center, can choose from a wide variety of activities on their way to attaining a meaningful self-determined role in the community.

“I was surprised to find out these activities were here and I have great expectations for learning how to reestablish hope for the future. I just hope some of the younger soldiers coming home today don’t wait as long as I did.”

— Veteran David FishVeteran David Fish uses his artistic skills as part of his recovery.

Dr. Jennifer Boyd Dr. Jennifer E. Boyd, who runs the San Francisco program, says the Veterans can select from dozens of activities that help them with social skills, self-expression, coping with symptoms, and striving for personal goals. In addition to offering classes, the program also pairs Veterans with staff Recovery Advisors who help them define and strive towards their personal goals. The interdisciplinary staff includes psychology, social work, nursing, occupational therapy, recreation/creative arts therapy, peer support, trainees, and volunteers. Many of the staff are board certified in Psychiatric Rehabilitation.

The wide range of activities in the program’s catalog are aimed at promoting community integration through effective symptom management and skill building.

For example, “Brainstorm” is a class that introduces Veterans to ways to boost their brain power. The “Dual Recovery” class focuses on alcohol and substance abuse recovery as it relates to mental health recovery. Uniquely, this class is facilitated by a staff member who has a dual diagnosis and is in recovery.

There are dozens more, like “Eating Right,” “Ending Self Stigma,” “Coping with Voices,” “Stress Management,” “Family Support,” “Women’s Group,” “Independent Living Skills,” and “Problem Solving.” There is also a “Student Council” which provides feedback to staff about the program.

There’s even a class called “Write Now,” where the Veteran students collaborate and enjoy a variety of recovery-oriented writing skills exercises including journaling, expressive writing, poetry, prose and more.

Classes Available at Multiple Locations

In addition to classes at the San Francisco Medical Center, the program is also available to Vets at clinics in downtown San Francisco, San Bruno and Santa Rosa.

Dr. Boyd is also enthusiastic about the introduction of teleconference classes which allows Veterans as far away and Ukiah and Eureka in northern California to participate.

One of the most popular courses is the “Veteran’s Art Guild,” where Veterans work on their self-determined art projects. In addition to improving physical stamina and manual dexterity, the class allows the Vets to visualize their recovery goals through their chosen means of artistic expression. The Guild is a bridge to the community because it has had numerous well received art shows and is working on becoming independent from the VA.

For David Fish, an Army Desert Storm Veteran, the program “has changed my life.”

A medic and paratrooper for eight years, David receives VA treatment for PTSD and major depression.

When not on duty as a nurse, David doodled around, drawing cartoons on his buddies’ t-shirts. Some of his work caught the eye of the editor of an Army newspaper who asked him to draw a comic strip for the paper. His work was good enough to be entered in a “morale boosting” competition which he won with an eight panel cartoon featuring two “desert rats.”

After a couple of decades struggling with his PTSD back home, David was finally convinced by family to seek help at the VA.

“When I came to the VA, I immediately identified with all the Veterans. I had to admit that I missed the Army. After all, it was my adult life. I had a hard time learning how to be a civilian.

“Dr. Boyd got me involved in the program. She has been fantastic.”

Today, David is using his drawing and writing skills as part of his recovery in the Psychosocial Rehabilitation and Recovery program. In addition to the mural on the medical center wall, pictured here, he participates with the Veterans Art Guild, writing interpretive descriptions of creative dances.

He’s also working on a book about his experiences in the Army.

“I was surprised to find out these activities were here and I have great expectations for learning how to reestablish hope for the future. I just hope some of the younger soldiers coming home today don’t wait as long as I did.”

At each of the major VA Medical Centers, the Psychosocial Rehabilitation and Recovery Center (PRRC) is a transitional education center designed to inspire and assist Veterans in reclaiming their lives by instilling hope and validating their strengths.

The program was started at the San Francisco VAMC in 2008 and has grown rapidly from an initial enrollment of 110 to a projected attendance of 1,086 in 2011. Currently, there are 175 Veterans in the San Francisco program.

More than 1500 Vets have Completed Courses

Dr. Boyd points out that more than 1500 Veterans have “completed” courses in the program, careful not to call them “graduates.” “We focus on the Vets achieving their own personal goals, getting whatever they want, and need, out of the classes. The classes are completely voluntary.”

“The Vets in our classes are about evenly split between Viet Nam era Vets and those from more recent eras such as Desert Storm, Iraq and Afghanistan.”

The Psychosocial Rehabilitation and Recovery program is an adjunct program that is available to Veterans who have a severe mental illness such as schizophrenia, bipolar disorder and associated impairment, and are followed in a Mental Health clinic by a principal mental health provider.

Dr. Boyd says, “It is a privilege to work with world-class colleagues offering the latest evidence-based practices. It’s wonderful to see Veterans change from being dominated by their illnesses to having a more full life with the illness only one aspect of it. Even if symptoms return, they may be less severe, shorter-lasting, or have less of an impact on other areas of life.

Veterans who have participated in the program may be less affected by internalized stigma of mental illness as well. We are just beginning to collect data on our program’s recovery outcomes.”

Dr. Jennifer Boyd is Associate Adjunct Professor in the Department of Psychiatry at the University of California, San Francisco. As Director of the Psychosocial Rehabilitation and Recovery Center at the San Francisco VA, she oversees a program of twelve staff members plus students and volunteers.

An oft-invited speaker on mental illness and stigma, including a presentation at the Moscow State University Psychology Department, and VA Psychosocial Rehabilitation and Recovery Centers Annual Meetings, Dr. Boyd received the American Psychological Association 2009 Award for Outstanding Contributions in Psychosocial Rehabilitation.

“My focus is primarily on reducing stigma for people with mental illnesses, and secondarily on improving cross-cultural and interdisciplinary interactions.

“I am an active member of “Stamp Out Stigma,” an organization that provides people with mental illness to speak at a variety of venues, including elementary schools, high schools, colleges, professional schools, police academies, suicide hotline training centers, international conferences, professional workshops, and government committees.”

In clinical, research, and community work, Dr. Boyd and her co-workers try to include stakeholders with mental illness in the operating and decision making processes, following the motto, “Nothing About Us Without Us.”

Courtesy of MilitaryTimes.com May 18, 2011

Combat veterans are being poorly served as a result of weak coordination between the Defense and Veteran Affairs departments, a key senator said Wednesday.

Sen. Patty Murray, D-Wash., the Senate Veterans Affairs Committee chairwoman, said drug abuse and suicides among recently separated combat veterans can be partly blamed on inadequate coordination as service members leave the military and become the responsibility of VA.

A lack of coordination also hurts treatment of combat-related wounds. Amputees are an example, Murray said.

“Where DoD has outstanding prosthetics, VA needs to do much better,” she said. “I was shocked to hear of a veteran who, after receiving advanced prosthetics from the military, went to VA to have them adjusted and maintained. When the veteran got to the prosthetic clinic, the VA employees were fascinated by the device, having never seen that model before, and were more interested in examining it than the veteran.”

The services have used narcotics heavily to treat service members, with the Army reporting 14 percent of soldiers have been prescribed an opiate, with a third of them being prescribed more than once, Murray said.

“It is imperative that these individuals receive a truly seamless handoff to VA medical care so a provider there can manage those medications after the individual has left the service,” Murray said. “If that link is not made, those new veterans become far more likely to abuse drugs, become homeless or commit suicide.”

The ranking Republican on the veterans panel also criticized cooperation and said it appears in some cases that the result has been more bureaucracy rather than better service. The prime example for Sen. Richard Burr, R-N.C., is a new, consolidated disability evaluation system that takes, on average, 394 days to fully process a service member — and in some cases, like at Camp Lejuene, N.C., 1½ years.

Scott Gould, VA’s deputy secretary, said the new evaluation system is working to eliminate differences between the services and between DoD and VA in disability ratings and that processing time is coming down.

William Lynn, deputy defense secretary, said the goal is to have claims processed within 300 days, a goal that could be achieved in “one to two years.”

Murray noted that the suicide rate among people going through the disability system is twice as high as for the rest of the military.

“Something isn’t working,” she said as Lynn and Gould spoke of programs to prevent suicide and drug abuse.