Original Research

Telejustice: Reaching Incarcerated Veterans via Telehealth

Telehealth offers a method to improve the efficiency of specialists in the Veterans Justice Outreach program and expands its delivery of associated services.

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References

The mission of the veterans justice programs (VJPs), which began in 2007 with the initiation of Health Care for Re-entry Veterans (HCRV) and expanded in 2009 to include Veterans Justice Outreach (VJO), is to prevent homelessness and provide justice-involved veterans with timely access to mental health and substance abuse services or other VA benefits.1 About 50% of homeless veterans have a history with the criminal justice system, and about 10% of all individuals incarcerated in the U.S. are veterans.2

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As the VA’ s use of telehealth services increases at non-VA settings, new opportunities emerge to reach veterans. One such population is incarcerated veterans, who can receive VJO and HCRV services. This article focuses primarily on the implementation of jail/prison outreach via clinical video telehealth (CVT) by VJO, which has already expanded to court liaison work (also provided by VJO) and may further expand to jail/prison outreach by HCRV. The article also describes the development and implementation of the VA’ s first telejustice program (TJP) at the VA Portland Health Care System (HCS) and briefly presents a second TJP at the VA New Jersey HCS Lyons Campus. Currently, there are about 15 known telejustice programs across the VA (Table 1).

Background

Overall, there were about 57,000 veterans seen in VJPs in fiscal year (FY) 2014, an estimated 11% increase over the previous year and an estimated 45% increase from FY12.3 Until November 2012, incarcerated veterans were able to access VJO services only by a face-to-face visit with traveling VA providers. Clinical video telehealth, conducted between a patient and a provider through real-time two-way communication, is a viable option to help improve access to care. In FY14, there were about 248,000 unique veterans who used CVT technologies to access about 660,000 appointments.4

Telemental health (TMH) via clinic-based CVT was first implemented in the VA in 2003. To date, more than 500,000 TMH encounters have occurred. Clinical video telehealth into the home (CVT-IH), which is focused on nonclinic settings was implemented nationally by VHA telehealth services in February 2013. Utilization of CVT-IH has increased from about 1,300 veterans seen (about 6,900 visits) in FY12 to about 4,200 veterans seen (about 20,000 visits) in FY14.4 Nationally, from June 2011 to April 2014, about 150 veterans received some form of VJO services via telehealth through a total of about 500 visits.

Each VAMC has a VJO specialist who serves as a liaison between the VA and law enforcement, court (particularly Veterans Treatment Courts and other collaborative treatment courts), and jails. About 225 VJO specialists provide a variety of services, including outreach, treatment matching/linkage assessment, court liaison and court team participation, and education/training to law enforcement on veteran-centric issues such as posttraumatic stress disorder (PTSD) and traumatic brain injury. Specialists spend significant time traveling to provide these jail/prison
outreach services.

The VA Portland HCS specialist, a licensed clinical social worker, had been in contact with representatives at the Deschutes County Adult Jail in Oregon and had determined there were veterans who could benefit from VA services, but she was unable to make the 322-mile round-trip in 1 day to conduct her visits. She contacted Peter Shore, PsyD, in 2010, then a clinical psychologist at the same VA who was conducting home-based TMH visits, and inquired whether it would be possible to see veterans in the jail via a webcam and personal computer. That was the start of the first VA telejustice program.

Portland Pilot

The VJO specialist at the VA Portland HCS initiated this project in early 2012. The Portland TJP used the same technology, staff, and approach that had been implemented in December 2009 through the Home-Based TMH (HBTMH) pilot. The HBTMH pilot (2009-2012), which predated the national CVT-IH program, included about 40 mental health care providers. It was the first VA pilot to successfully connect providers with veterans in their homes via Internet, webcam, and personal computer. During this period, about 250 veterans were seen in an estimated 750 clinical encounters. About 80% of those enrolled indicated they would not have received any mental health treatment were it not for the availability of HBMTH.

In May 2012, Dr. Shore was awarded a VHA Innovation grant through the VA Office for Innovation to expand the HBTMH pilot to VISN 20 via VHA Innovation 669. The Portland TJP was able to expedite implementation through the grant. In addition to continuing the mission of the HBTMH pilot to deliver behavioral health services into the homes of veterans, the Innovation 669 program was established to focus on the advancement of clinical video visits into a variety of non-VA settings, using alternative technologies, including iPads, netbooks, and alternatives to Cisco Jabber (San Jose, CA), the VA-approved videoconferencing software.

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