Needsassessment2015 Mobha

MISSOURI MILITARY
COMMUNITY HEALTH
NEEDS ASSESSMENT
2015
SERVICE MEMBERS, VETERANS, FAMILY
MEMBERS, AND SERVICE PROVIDERS
PREPARED BY:
UNIVERSITY OF
MISSOURI-KANSAS
CITY INSTITUTE FOR
HUMAN
DEVELOPMENT FOR
MISSOURI
BEHAVIORAL
HEALTH ALLIANCE
AND MISSOURI
TRAUMATIC BRAIN
INJURY
PARTNERSHIP
The information contained in this document has been commissioned by the Missouri Behavioral Health
Alliance and the Missouri Traumatic Brain Injury Partnership Project, and produced by the University of
Missouri-Kansas City Institute for Human Development. Funding for this assessment was made possible to the
Missouri Department of Mental Health by Missouri Health Foundation, and Missouri Traumatic Brain Injury
Partnership Project by Health Resources and Services Administration. This document is intended for use by
policy makers, research organizations, nonprofit service providers, governmental agencies, and all others
seeking to understand the complexities of the mental and behavioral health needs of Missouris Veterans and
their families. The authors were encouraged to express freely their findings and conclusions. Points of view or
opinions do not, therefore, necessarily represent official positions of the Missouri Behavioral Health Alliance,
the Missouri Traumatic Brain Injury Partnership Project, or the Curators of the University of Missouri on behalf
of the University of Missouri-Kansas City.
All material appearing in this document is in the public domain and may be reproduced or copied without
permission from the University of Missouri-Kansas City. This publication MAY NOT be reproduced or
distributed for a fee.
Suggested Citation: Petri, A.N., and Gee, R. (2015). Missouri Military Community Health Needs Assessment
2015. Kansas City, MO: University of Missouri-Kansas City Institute for Human Development.
MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT
2015
MISSOURI MILITARY
COMMUNITY HEALTH NEEDS
ASSESSMENT
By Alexis Petri, Ed.D. and Ryan Gee, M.A.

August 2015
2015
Acknowledgements
We would like to express our gratitude for the support of the many individuals who provided
assistance for the Missouri Military Community Health Needs Assessment:
Jon Sabala, Veterans Services Director, Missouri Department of Mental Health, who
provided leadership and guidance for the project.
Dean Andersen, who disseminated the online survey, coordinated focus groups, and
assisted with focus group facilitation.
People from the following organizations shared their insights and expertise to make the needs
assessment possible:
General Leonard Wood Community Hospital TBI Program

H.E.R.O.S. Care
Missouri Association of College Military Education
Missouri Behavioral Health Alliance
Missouri Department of Health and Senior Services Division of Community and Public Health
Section for Special Health Services
Missouri Department of Mental Health
Missouri Traumatic Brain Injury Partnership Project
Missouri Veterans Commission
United Way of Greater Kansas City Veterans Alliance
University of Central Missouri Office of Military and Veteran Services
University of Missouri-Kansas City Institute for Human Development
University of Missouri Veterans Center
Wounded Warrior Project Kansas City
The funding for this project is provided in part by the Maternal and Child Health Bureau (Title V,
Social Security Act), Health Resources and Services Administration, Department of Health and
Human Services. Grantees undertaking projects under government sponsorship are encouraged to
express freely their findings and conclusions. Points of view or opinions do not, therefore,
necessarily represent official positions of the Health Resources and Services Administration, nor do
they represent official positions of the Department of Health and Senior Services or the University of
Missouri-Kansas City.
Funding for this project is provided in part by the Missouri Foundation for Health. Missouri
Foundation for Health is a resource for the region, working with communities and nonprofits to
generate and accelerate positive changes in health. As a catalyst for change, the Foundation
improves the health of Missourians through partnership, experience, knowledge, and funding.
2015
Executive Summary
The Missouri Military Community Needs Assessment gathered information from Veterans, Service
Members, family members of Veterans and service providers on the health care needs of and
available to the Missouri military community, with an emphasis on traumatic brain injury, mental
health, and substance use. The goal of the needs assessment was to systematically identify needs
and measure the gaps between current conditions and wanted conditions through participation of
Veterans, Service Members, family members, and behavioral health and health service providers.
The needs assessment sought to answer the following broad questions:
What obstacles do Service Members, Veterans, and their families face in accessing services?
What is the current network of support available?
How accessible is the network of support?
Where are there gaps in services and

systems?
A total of 475 people completed the online survey:

461 surveys were complete; 14 were incomplete.
The survey was completed by a total of 357
Service Members, Veterans, and family members,
and 118 Veterans services providers.
Some of the providers are also Veterans: 14%
(n=15) of providers have served in the United
States Armed Services, and 80% served active
duty. A range of providers completed the survey:
36% of respondents were counselors; 30%
administrators; and 14% social workers.
Figure ES1. Survey Respondents

4% 6%
Figure ES1. Survey Respondents
41%
49%
Current Service Members

Former Military Service Member
Family Members of SM
Family Member of Veteran
2015
Transition
Veterans participating in the online survey responded to questions about the type of and quality of
health information received at time of separation.
Figure ES2. Quality of Health Information Received at Separation, by Age
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
No Information
Inadequate Information
18-24 years old

45-64 years old
2 per. Mov. Avg. (25-44 years old)
Physical Health
TBI
Substance Use
Mental Health
Physical Health
TBI
Substance Use
Mental Health
Physical Health
TBI
Substance Use
Menatl Health
0%
Thorough Information
25-44 years old

65 years or older
Figure ES3. Leaving Military Service with Untreated Health Issues, by Age
100%
100%
87%
80%
68%
58%
60%
42%
52% 48%
32%
40%
20%
13%
0%
0%
18-24 years old

(n=3)
25-44 years old

(n=63)
45-64 years old

(n=104)
Yes
65 years or older
(n=21)
Total (n=191)
No
2015
Insurance and Health Providers

Health Insurance
A majority of Service Members, 84%, have TRICARE. Veterans and family members have a variety of
health care insurance, everything from VA healthcare, to the insurance offered through an
employer, to no insurance. Many had more than one type of insurance. Of Veterans who are not
incarcerated, 6% have no health insurance.
Figure ES4. Type of Health Insurance
100%
84%
80%
60%
40%
20%
62%
41% 38%
6%
2%
32%
31%
2% 7% 5% 4%
54%
52%
2%
9%
12%
3% 0%
8% 5%
6% 0% 0%
0%
Current or
former
employer
Purchased
directly from an
insurance
company
TRICARE
Veteran
(Notincarcerated)
DOC) (n=144)
Veteran (not
(n=144)
Family Member (n=27)
Medicare,
Medicaid,
medical
V.A. Health Care
No health
insurance
Service Member (n=118)

DOC
(n=50)
Veteran
(incarcerated) (n=50)
Veterans Health
Providers and family members were asked Do you feel a substantial amount of military Service
Members and Veterans have untreated mental and/or physical health issues?
Figure ES5. Perceptions of Untreated Mental and/or Physical Health Issues
100%
87%
82%
50%
18%
13%
0%
Yes
Providers
No
Family Members of Veterans
2015
Barriers to Health Services

Figure ES6. Barriers to Professional Healthcare Services by Respondent Type
80%
70%
67%
60%
60%
54%
52%
50%
44%
44%
40%
38% 37%
40%
34%
33%
31%
30%
20%
20%
14%
27%
25% 26%
22%
25%
17%
16%
12%
9% 11%
11%
15%
10%
3%
0%
0%
Geography
Veterans
Stigma
Inadequate
insurance
Service Member
Lack of
insurance
Clinic hours
Family Member
Paperwork
I do not know
about available
resources
Providers
Total
Traumatic Brain Injury

The survey asked respondents specifically about traumatic brain injury. Of the 331 respondents, 22%
(n=73) responded yes, they had or their family member had experienced either a traumatic brain
injury or an injury to the head during service. Service Members and Veterans responding yes were
asked whether they were screened at the time of the event or shortly thereafter specifically for a
TBI. Most said that they were not screened at the time or soon thereafter, 62% of Service Members
and 80% of Veterans.
2015
Mental Health
The survey asked Are Service Members and Veterans getting the care they need for mental health
injuries, including Combat-related Stress? Looking at all of the Service Member, Veteran, and
Family member respondents, 63% answered No, and 37% answered Yes.
Figure ES7. Are Service Members and Veterans Getting Care they need?
Service Members
52%
Veterans
31%
Family Members
Providers
48%
69%
9%
91%
7%
93%
All
37%
0%
10%
20%
63%
30%
40%
50%
Yes
60%
70%
80%
90%
100%
No
Suggested Priority Areas for Action
Offer continuing education courses on military culture for civilian service providers.
Offer continuing education courses on how to support Veterans in accessing services from
the VA to civilian service providers and family members.
Research and provide resources on traumatic brain injury to service providers to increase
familiarity with the screening process, how TBI effects behavior, treatment process, and
survivor resources.
Local communities could offer transition support to Veterans and family members either
returning home or relocating. These resources would be at the very local level to support
the transition process and help welcome Veterans and families.
Help Veterans connect with local, specific online resources for behavioral health that helps
retain privacy and connects Veterans needing help with well-trained, resourceful people.
2015
Table of Contents
ACKNOWLEDGEMENTS ................................................................................................................................... 2
EXECUTIVE SUMMARY .................................................................................................................................... 3
TRANSITION .......................................................................................................................................................... 4
INSURANCE AND HEALTH PROVIDERS ......................................................................................................................... 5
VETERANS HEALTH ................................................................................................................................................ 5
BARRIERS TO HEALTH SERVICES ................................................................................................................................. 6
TRAUMATIC BRAIN INJURY ....................................................................................................................................... 6
MENTAL HEALTH ................................................................................................................................................... 7
SUGGESTED PRIORITY AREAS FOR ACTION ................................................................................................................... 7
INTRODUCTION ............................................................................................................................................ 12
STUDY PROCEDURES ..................................................................................................................................... 12
VETERANS PROFILE IN MISSOURI .................................................................................................................. 13
EDUCATION......................................................................................................................................................... 13
EMPLOYMENT ..................................................................................................................................................... 13
DISABILITY .......................................................................................................................................................... 14
SUBJECT POPULATION .................................................................................................................................. 15
CHARACTERISTICS OF SURVEY PARTICIPANTS ............................................................................................... 15
SERVICE MEMBERS, VETERANS, AND FAMILY ............................................................................................................. 15
ACTIVE DUTY ................................................................................................................................................ 16
PROVIDERS ......................................................................................................................................................... 18
GEOGRAPHY ................................................................................................................................................. 19
TRANSITION .................................................................................................................................................. 20
INSURANCE AND HEALTH PROVIDERS .......................................................................................................... 22
HEALTH INSURANCE .............................................................................................................................................. 22
PROVIDERS TRAINING ........................................................................................................................................... 24
VETERANS HEALTH ...................................................................................................................................... 25
TRAUMATIC BRAIN INJURY ..................................................................................................................................... 27
MENTAL HEALTH ................................................................................................................................................. 28
SUBSTANCE USE................................................................................................................................................... 31
SERVICES....................................................................................................................................................... 31
VETERANS PERSPECTIVES ....................................................................................................................................... 33
PROVIDERS PERSPECTIVES ..................................................................................................................................... 34
FOCUS GROUP FINDINGS .............................................................................................................................. 35
2015
VETERANS ...........................................................................................................................................................35
PROVIDERS ..........................................................................................................................................................37
DISCUSSION AND IMPLICATIONS .................................................................................................................. 41
WHAT OBSTACLES DO SERVICE MEMBERS, VETERANS, AND THEIR FAMILIES FACE IN ACCESSING SERVICES? .............................41
WHAT IS THE CURRENT NETWORK OF SUPPORT AVAILABLE? ...........................................................................................42
HOW ACCESSIBLE IS THE NETWORK OF SUPPORT? ........................................................................................................42
WHERE ARE THERE GAPS IN SERVICES AND SYSTEMS? ...................................................................................................43
COMPARISON WITH IAVA VETERANS SURVEY.............................................................................................................43
SUGGESTED NEXT STEPS ............................................................................................................................... 45
SUGGESTED PRIORITY AREAS FOR ACTION ..................................................................................................................45
APPENDICES .................................................................................................................................................. 46
APPENDIX A: FOCUS GROUP SCRIPTS ........................................................................................................................46
APPENDIX B: ONLINE SURVEY..................................................................................................................................47
2015
Table of Tables
TABLE 1. SURVEY RESPONDENTS BY CATEGORY, AGE, AND GENDER _________________________________ 16
TABLE 2. SURVEY RESPONDENTS BY ETHNICITY AND RACE ________________________________________ 16
TABLE 3. COMPARISON BY AGE WITH OTHER DATA SOURCES ______________________________________ 17
TABLE 4. HOW RESPONDENTS CONNECTED WITH TBI SERVICES ____________________________________ 28
TABLE 5. HOW RESPONDENTS CONNECTED WITH MENTAL HEALTH SERVICES _________________________ 30
TABLE 6. SERVICES USE, NEED, AND RATING ____________________________________________________ 32
TABLE 7. VETERANS PERSPECTIVE ON SERVICES USED AND NEEDED _________________________________ 33
TABLE 8. PROVIDERS PERSPECTIVE ON SERVICES USED AND NEEDED ________________________________ 34
10
2015
Table of Figures
FIGURE ES1. SURVEY RESPONDENTS ......................................................................................................................3
FIGURE ES1. SURVEY RESPONDENTS ......................................................................................................................3
FIGURE ES2. QUALITY OF HEALTH INFORMATION RECEIVED AT SEPARATION, BY AGE ........................................4
FIGURE ES3. LEAVING MILITARY SERVICE WITH UNTREATED HEALTH ISSUES, BY AGE .........................................4
FIGURE ES4. TYPE OF HEALTH INSURANCE ............................................................................................................5
FIGURE ES5. PERCEPTIONS OF UNTREATED MENTAL AND/OR PHYSICAL HEALTH ISSUES ....................................5
FIGURE ES6. BARRIERS TO PROFESSIONAL HEALTHCARE SERVICES BY RESPONDENT TYPE ..................................6
FIGURE ES7. ARE SERVICE MEMBERS AND VETERANS GETTING CARE THEY NEED? ..............................................7
FIGURE 1. PERCENTAGE OF MISSOURI CIVILIAN POPULATION 18 AND OVER WITH DISABILITIES ......................14
FIGURE 2. SURVEY RESPONDENTS BY ROLE SERVICE MEMBERS, VETERANS, AND FAMILY ..............................15
FIGURE 3 (RIGHT). SURVEY RESPONDENTS BY ACTIVE DUTY STATUS ..................................................................16
FIGURE 4. PROVIDERS BY POSITION .....................................................................................................................18
FIGURE 5. ESTIMATED NUMBER OF IRAQ/AFGHANISTAN VETERANS DEPLOYED BY COUNTY SINCE SEPTEMBER
2001 ......................................................................................................................................................................19
FIGURE 6. PROVIDERS BY ZIP CODE ......................................................................................................................19
FIGURE 7. VETERANS AND FAMILY MEMBERS BY ZIP CODE ................................................................................19
FIGURE 8. QUALITY OF HEALTH INFORMATION RECEIVED AT SEPARATION ........................................................20
FIGURE 9. LEAVING MILITARY SERVICE WITH UNTREATED HEALTH ISSUES, BY INCARCERATED POPULATION ..21
FIGURE 10. LEAVING SERVICE WITH UNTREATED HEALTH ISSUES, BY AGE .........................................................21
FIGURE 11. TYPE OF HEALTH INSURANCE ............................................................................................................22
FIGURE 13. SERVICE MEMBERS AND VETERANS PERSPECTIVE OF MILITARY CULTURE KNOWLEDGE ................23
FIGURE 12. PROVIDERS PERSPECTIVE OF MILITARY LIFE AND CULTURE KNOWLEDGE .......................................23
FIGURE 14. PROVIDERS PROFESSIONAL TRAINING BY TOPIC ...............................................................................24
FIGURE 15. PROVIDERS EQUIPPED TO SCREEN AND ACCESS TO RESOURCES.....................................................25
FIGURE 16. PERCEPTIONS OF UNTREATED MENTAL AND/OR PHYSICAL HEALTH ISSUES ....................................25
FIGURE 17. BARRIERS TO PROFESSIONAL HEALTHCARE SERVICES BY RESPONDENT TYPE ..................................26
FIGURE 18. BARRIERS BY PROVIDER FAMILIARITY WITH RESOURCES ..................................................................27
FIGURE 19. ARE SERVICE MEMBERS AND VETERANS GETTING CARE THEY NEED? .............................................28
FIGURE 20. RATING OF SERVICES FOR SUPPORTING VETERANS MENTAL HEALTH CONCERNS ..........................29
11
2015
Introduction
The Missouri Military Community Needs Assessment gathered information from Veterans, Service
Members, family members of Veterans, and service providers on the health care needs of and
available to the Missouri military community, with an emphasis on traumatic brain injury, mental
health, and substance use. UMKC Institute for Human Development worked with the Missouri
Behavioral Health Alliance to develop research questions, survey questions, and follow-up focus
group questions. The Missouri Behavioral Health Alliance also assisted with sharing the needs
assessment project with Service Members, Veterans, and health providers. The goal of the needs
assessment was to systematically identify needs and measure the gaps between current conditions
and wanted conditions through participation of Veterans, Service Members, family members, and
behavioral health and health service providers. The needs assessment sought to answer the
following broad questions:
What obstacles do Service Members, Veterans, and their families face in accessing
services?
Where are there gaps in services and systems?
Study Procedures
UMKC-IHD employed several strategies to collect data from multiple sources to determine the
mental and behavioral health needs of Missouris Service Member, Veteran, and family population.
The first stage was two online surveys. One survey was for service providers in Missouri. The other
survey was for Service Members, Veterans, and family members. The service provider survey
questionnaire included 42 questions regarding the professionals affiliation, service they are
providing, their knowledge, training requirement and their perception of barriers and gaps in the
service. The second survey was for Service Members, Veterans and their families. The survey used a
branching logic and depending on the respondent had from 23 to 42 questions. Both of the online
surveys were anonymous and took approximately 15 minutes to complete. The needs assessment
was also available on paper for situations where paper and pencil surveys were more feasible. The
online survey questions were designed to be non-invasive. However, that judgement was up to the
individual. To the extent possible there was an option to check a box that reads "prefer not to
12
2015
respond." The participants also had the option to start and stop, and then continue the survey at
another time. They could also opt to not complete the survey if they wished.
Working through the collaborative network established by gathering data, the needs assessment
team conducted a series of focus groups and telephone interviews throughout the state of Missouri.
Participation in the focus groups and telephone interviews was confidential. The focus group was a
follow up to the online survey to help clarify and validate the preliminary findings of the online
survey.
The findings of this needs assessment are not definitive; they suggest areas to explore in greater
depth and Veterans needs for resources and support. A rigorous research design with randomized
or stratified sampling and sufficient power was cost-prohibitive and not feasible. The findings should
be considered when improving policies and strengthening programs throughout the state.
Veterans Profile in Missouri

The 2013 Annual Estimate of Resident Population for Missouri is 6,007,182, and the Missouri civilian
population 18 years and over is 4,573,203, of which an estimated 479, 828 are Veterans (2009-2013
American Community Survey 5-year Estimates). According to the 2013
American Community Survey 5-year estimate, Missouri has a total
civilian population of 3,992,211 people 25 years and over, of which
473,483 are Veterans. Missouri Veterans are an aging population: 8.3%
are World War II Veterans; 11.8% served in the Korean War; 36% served
9.8% of Missouri
Veterans served
during the Gulf War
(9/2001 and later).
during the Vietnam era; 15.4% served during the Gulf War (1990 to
8/2001), and 9.8% served during the Gulf War (9/2001 and later).
Education
Missouri Veterans have more educational attainment than do nonveterans: 33.3% of Veterans are
high school graduates compared with 31.4%; 35% of Veterans have some college or an associates
degree, compared with 29.1%. However, the nonveteran population is more likely to have a college
degree, 26.6% of nonveterans compared with 22.4% of Veterans.
Employment
Looking at the 3.7 million Missouri civilian population age 18 to 64 years, 273,133 are Veterans.
Veterans participate in the labor force at a slightly lower rate than nonveterans, 73.9% compared
with 77%; but, Veterans have a lower unemployment rate of 7.9% compared with 8.7% of
13
2015
nonveterans. Looking at employment by age, younger Veterans (age 18-55) participate in the labor
force at greater percentages than nonveterans: 86.7% of Veterans age 18-34 compared with 78% of
nonveterans; 84% of Veterans age 35-54 compared with 81.4% of nonveterans.
A lower percentage of Veterans in Missouri live below the poverty line than nonveterans: 11.5% of
Veterans compared with 21.7% of nonveterans.
Disability
At every age, Veterans are more likely to have a disability than nonveteran Missourians.
Figure 1. Percentage of Missouri Civilian Population 18 and Over with Disabilities
50%
41.1%
40%
36.5%
30%
28.8%
20.5%
20%
10%
10.2%
6.6%
17.0%
12.7%
0%
18-34 Disability
35-54 Disability
Veteran
55-64 Disability
65+ Disability
Nonveteran
14
2015
Subject Population
Four populations participated in this needs assessment:
1) Service Members, current members of the U.S. Armed Forces.
2) Veterans who are living in Missouri.
3) Family members of Service Members and Veterans who have a Missouri residence.
4) Service providers who provide treatment and support for Service Members and Veterans.
Inclusion criteria: Participants must be a current Service Member or a Veteran; an adult family
member of a current Service Member or Veteran, or a service provider who works with Service
Members and Veterans. Participants must be over 18 years of age.
Exclusion criteria: Proposed participants lack military experience, are not related to a current or
former Service Member, or do not provide services to Service Members or Veterans.
Characteristics of Survey Participants

A total of 475 people completed the online
survey: 461 surveys were complete; 14 were
incomplete. The survey was completed by a
total of 357 Service Members, Veterans, and
family members, and 118 Veterans services
providers.
Figure 2. Survey Respondents by Role Service Members,

Veterans, and Family
4%
Service Members, Veterans,

and Family
Survey respondents were asked to identify
themselves as current Service Members,
former Military Service Member/Veteran,
family member of Service Members, or family
member of former Military Service
Member/Veteran.
6%
41%
49%
Current Service Members

Former Military Service Member
Family Members of SM
Family Member of Veteran
15
2015
Active Duty
One of the considerations of the survey is whether the respondent is currently or has ever been on
active duty, aside from basic training. 92% of the Service Members and Veterans either currently are
or have in the past been on active duty.
Figure 3 (right). Survey Respondents by Active
Duty Status
On Active
Duty Now
8%
31%
92% of Service Members and

Veterans surveyed have served on
active duty in the past or are
currently serving on active duty.
Active Duty
in Past
61%
Never on
Active Duty
Demographics
The following tables present an overview of the age, gender, race, and ethnicity of survey
respondents. A majority of survey respondents (80%) were between the ages of 25 and 64. Most of
the Service Members (62%) were ages 25-44 and most of the Veterans (54%) were ages 45-64.
Table 1. Survey Respondents by Category, Age, and Gender
SERVICE MEMBER, VETERAN, FAMILY MEMBER PARTICIPANTS, BY AGE & GENDER

Age
Gender
Number
18-24
25-44
45-64
65+
Male
Female
SMVF All
362
13%
43%
37%
7%
72%
28%
Service Member
118
28%
62%
10%
0%
81%
19%
Veteran
194
2%
33%
54%
11%
77%
23%
Incarcerated
50
0%
38%
46%
16%
98%
2%
Veteran (not
144
2%
31%
57%
10%
70%
30%
27
30%
41%
26%
4%
7%
93%
incarcerated)
Family Member
16
2015
Table 2. Survey Respondents by Ethnicity and Race
ETHNICITY
RACE
Latino/
Latina
Not
Latino/
Latina
Prefer not
to Respond
White
Black /
African
American
American
Indian
Asian
Pacific
Islander
SMVF All
9%
86%
5%
56%
12%
5%
3%
1%
Service
Member
Veteran
17%
80%
3%
69%
16%
3%
8%
3%
5%
90%
6%
81%
11%
7%
2%
0%
Veteran
Incarcerated
Veteran
2%
90%
8%
78%
14%
12%
0%
0%
6%
89%
5%
82%
8%
6%
2%
0%
4%
90%
6%
74%
11%
15%
0%
0%
(not
incarcerated)
Family
Member
Table 3. Comparison by Age with Other Data Sources
MO Military
Needs
Assessment
Veterans
Only
VA Living
Veterans
DOD
2012
Age
18-24
25-44
45-64
65 and over
Race and Ethnicity
White
Hispanic
Black
Multi-racial
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
Asian
Gender
Male
Female
13%
44%
37%
7%
2%
33%
54%
11%
1%
18%
35%
46%
79%
9%
13%
NA
1%
7%
4%
85%
5%
11%
NA
0%
8%
2%
70%
73%
77%
85%
27%
23%
15%
17%
3%
1%
2%
4%
17
2015
The previous tables show that the Missouri Military Community Health Needs Assessment
respondents were similar to the Veterans population as a whole. The first column shows the
combined race and ethnicity data for all respondents Veterans, Service Members, and family
members. The second column shows only the Veterans who answered the Veterans questions and
not the providers who are also Veterans. The Veterans responding to the needs assessment survey
were a younger group than the Veterans population (age 65 and over = 11% compared with age 65
and over = 46%).
Providers
Veteran services providers completed the online survey as well. Through use of branching logic,
their survey asked similar questions but framed from the perspective of a Veteran services provider.
Some of the providers are also Veterans: 14% (n=15) of providers have served in the United States
Armed Services, and 80% served active duty. Range of providers completed the survey: 36% of
respondents were counselors; 30% administrators; and 14% social workers.
Figure 4. Providers by Position
Doctor Mental Health

1%
Tech
Case Manager
1%
3%
Nurse
Practitioner
1%
Psychiatrist
1%
Other
7%
Psychologist
7%
Counselor
35%
Social Worker
14%
Administrator
30%
18
2015
Geography
To ensure the needs assessment
participants were representative of the
state of Missouri, we asked Service
Members, Veterans, and family
members to enter their zip code.
Veterans service providers were asked
to enter their work zip code. Figure 5
plots zip codes of Veterans and family
members who took the survey. Figure
6 shows size of deployment since
2001 by county. Visually, the pattern
of responding Veterans and families
matches the counties with the largest
numbers of Service Members
deployed since 2001 (still Service
Members and recent Veterans). Figure
7 shows the zip codes of responding
service providers.
Figure 5. Estimated Number of Iraq/Afghanistan

Veterans Deployed by County since September 2001
SOURCE: Defense Manpower Data Center (DMDC) # of
Deployments (Sept. 11, 2001 May 2012). US Census
Bureau Tiger County and State Shapefiles (2010).
Figure 6. Veterans and Family Members by Zip

Code
Figure 7. Providers by Zip Code
19
2015
Transition
Transition from military to civilian life can be difficult. During
Over 70% of Missouri
out-processing, Service Members participate in a transition
Veterans age 25-64 years old
assistance program course, which provides information and
left the military without any
training pertaining to employment, education, starting a
information on traumatic
business, transitional and Veteran Health Care, relocation
brain injury.
planning, Veteran programs, and much more. There is so
much information presented, it may be difficult for the
transitioning Service Member to retain it, and there may also
be gaps in what is presented, especially when it pertains to
health. Veterans participating in the online survey responded to questions about the type of and
quality of health information received at time of separation.
Figure 8. Quality of Health Information Received at Separation
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
No Information
Inadequate Information
Physical Health
TBI
Substance Use
Mental Health
Physical Health
TBI
Substance Use
Mental Health
Physical Health
TBI
Substance Use
Menatl Health
0%
Thorough Information
18-24 years old
25-44 years old
45-64 years old
65 years or older
2 per. Mov. Avg. (25-44 years old)
20
2015
The chart on the previous page shows that most Veterans received no information about mental
health, substance use, traumatic brain injury, and physical health. We looked closer at age and
noticed that the youngest Veterans, those age 18-24, are receiving information (67% received
thorough information on substance use and traumatic brain injury), while Veterans 65 years and
older received no information (100% received no information on traumatic brain injury; 89%
received no information on substance use; 83% received no information on mental health). Over
half of Veterans ages 25 to 44 received no information on mental health, substance use, and
traumatic brain injury. This may reflect recent changes to transition assistance programs.
The survey asked Veterans, Do you feel you left military service with untreated mental and/or
physical health issues? We looked at this two different ways, one by whether the Veteran was also
currently incarcerated, and by age. A higher percentage of Veterans currently serving sentences in a
correctional facility (88%) feel they left military service with untreated health issues, than
responding Veterans not currently incarcerated (61%). We also looked at this question by age: 68%
of Veterans feel they left military service with untreated mental and/or physical health issues, and
87% of Veterans age 25 to 44 feel they left military service with untreated mental and/or physical
health issues.
Figure 9. Leaving Military Service with untreated Health Issues, by
Incarcerated Population
68% of Veterans
feel they left
military service with
untreated mental
and/or physical
health issues.
Veteran- All
68%
Veteran- Not Incarcerated
32%
61%
Veteran- Incarcerated
39%
88%
0%
20%
Yes
40%
12%
60%
80%
100%
No
Figure 10. Leaving Service with Untreated Health Issues, by Age

100%
100%
87%
80%
68%
58%
60%
42%
52% 48%
32%
40%
13%
20%
0%
0%
18-24 years old (n=3)
25-44 years old

(n=63)
45-64 years old

(n=104)
Yes
65 years or older
(n=21)
Total (n=191)
No
21
2015
Insurance and Health Providers

Health Insurance
Insurance coverage is an important facet when considering the health needs of Service Members,
Veterans, and their family members. The question asked what type of health insurance do you have,
and respondents could check multiple boxes. A majority of Service Members, 84%, have TRICARE.
Veterans and family members have a variety of health care insurance, everything from VA
healthcare, to the insurance offered through an employer, to no insurance. Many had more than
one type of insurance. Of Veterans who are not incarcerated, 6% have no health insurance.
Figure 11. Type of health insurance
100%
84%
80%
62%
60%
40%
54%
52%
41% 38%
32%
31%
20%
6%
2%
2%
7% 5% 4%
9%
2%
12%
3% 0%
8% 5%
6%
0% 0%
0%
Current or
former
employer
Purchased
directly from an
insurance
company
TRICARE
Veteran (Not
DOC) (n=144)
(not incarcerated)
(n=144)
Family Member (n=27)
Medicare,
Medicaid,
medical
V.A. Health Care
No health
insurance
Service Member (n=118)

Veteran
(incarcerated) (n=50)
DOC
(n=50)
22
2015
Knowledge of Military Life and Culture

The survey asked: In general terms, how knowledgeable are non-VA health care providers about
military life and culture? Most (72%) providers indicated that few non-VA health care providers are
knowledgeable about military life and culture. Of the 303 Service Members and Veterans answering
the question, 26% had not received services from non-VA health care providers. Service Members
and Veterans felt more non-VA providers were knowledgeable with 32% indicating most were
knowledgeable about military life and culture.
Figure 12. Providers Perspective of Military
Life and Culture Knowledge
Figure 13. Service Members and Veterans

Perspective of Military Life and Culture
Knowledge
1% 3%
10%
24%
40%
18%
72%
32%
Few
Most
All
None
Few
Most
All
None
23
Timely VA Ratings decisions and
seeing specialists takes forever to get

an appointment; also lack of
continuity of care - I've had 4 primary
care physicians in 7 years!
Survey comment
Now that I am turning 65, I cannot

see my provider anymore. I have
been seeing her for over 25 years.
Survey comment
2015
Providers Training
The survey asked providers what training they
received in their professional education; the
question provided general categories
traumatic brain injury, substance use, mental
health, and post-traumatic stress disorder.
Respondents could check as many boxes as
relevant and they could also check no boxes.
Figure 14 presents the percentage of providers
out of all the respondent providers who
indicated they had training on that topic. Most
providers had training on mental health (84%)
and more than half had training on substance
use (65%) and post-traumatic stress disorder
(65%). Few (32%) had training on traumatic
brain injury.
Figure 14. Providers Professional Training by Topic
100%
84%
80%
65%
65%
60%
40%
32%
20%
0%
TBI
Substance Use
Mental Health
PTSD
The providers survey asked a series of questions related to screening and resources. A majority of
providers feel adequately equipped to screen for mental health issues (75%) and have resources to
share (71%). When it comes to traumatic brain injury, providers do not feel adequately equipped to
screen (65%) or feel it is not applicable to their work (15%) and most (62%) do not have access to
resources to share with Veterans and family members about traumatic brain injury.
24
2015
Figure 15. Providers Equipped to Screen and Access to Resources
80%
75%
65%
71%
62%
No
60%
38%
40%
20%
20%
15%
16%
0%
0%
TBI Equipped to
Screen
TBI Resources
Veterans Health
25%
9%
Yes
4%
NA
Mental Health
Mental Health
Issues Equipped Issue Resources
to Screen
Some veterans do not want to admit

there is something wrong until
something bad happens.
One of the primary concerns of this needs

assessment is whether Service Members and
Veterans have untreated mental and/or physical
Survey comment
health issues. Providers and family members
were asked Do you feel a substantial amount of
I'm in prison with lack of proper
military Service Members and Veterans have
diagnosis.
untreated mental and/or physical health
issues? In answer to that question, 87% of
Survey comment
health care providers and 82% of family
members indicated they feel a substantial
amount of military Service Members and
Veterans have untreated mental and/or physical health issues.
Figure 16. Perceptions of Untreated Mental and/or Physical Health Issues
100%
87%
82%
80%
60%
40%
18%
13%
20%
0%
Yes
Providers
No
Family Members of Veterans

25
2015
The needs assessment sought to understand what the barriers might be for Service Members and
Veterans to seek treatment for any mental or physical health concerns. Respondents were asked,
What do you feel are barriers to accessing professional healthcare services, and were instructed to
check all that apply. As has been the trend throughout the analysis, providers saw more barriers
than Service Members, Veterans, and family members. For each type of respondent, the top barriers
were the same: Stigma (67% of providers, 52% of family members, 44% of Service Members, 31% of
Veterans); geography either too far to drive or lack of transportation (60% of providers, 44% of
family members; 25% of Service Members; 34% of Veterans); and lack of knowledge about services
and resources (37% of family members; 27% of Service Members and 38% of Veterans; only 15% of
providers selected this as a barrier).
Figure 17. Barriers to Professional Healthcare Services by Respondent Type
80%
70%
67%
60%
60%
54%
52%
50%
44%
44%
40%
38% 37%
40%
34%
33%
31%
30%
27%
25% 26%
22%
25%
14%
20%
20%
17%
16%
12%
9% 11%
11%
15%
10%
3%
0%
0%
Geography
Stigma
Veterans
Providers
Inadequate
insurance
Lack of
insurance
Clinic hours
Service Member
Total
Paperwork
I do not know
about available
resources
Family Member
To better understand the gap between the providers perspectives and those of Service Members
and Veterans, we conducted crosstab analysis of the providers answers. Providers who were more
familiar with Service Member or Veteran specific resources selected more barriers. For example,
26
2015
73% of providers familiar with resources selected geography and stigma as the top two barriers
while providers less familiar selected stigma (62%) and geography (47%). Providers who were not
familiar with resources were more likely to select I do not know about services and resources that
are available (21% compared with 10%).
Figure 18. Barriers by Provider Familiarity with Resources
80%
73%
73%
70%
62%
63%
60%
50%
47%
45%
40%
47%
32%
30%
22%
20%
21%
20%
13%
10%
10%
2%
0%
Geography
Stigma
Inadequate
health
insurance
Familiar
Lack of health Clinic hours

insurance interfere with
work
Not Familiar
Paperwork
I do not know
about services
and resources
Total
Traumatic Brain Injury

The survey asked respondents specifically about traumatic brain injury: During your military
service, did you experience a traumatic brain injury or an injury to your head? For example, were
you near a blast, struck by debris, fall and hit your head, etc.? Of the 331 respondents, 22% (n=73)
responded yes, they had or their family member had experienced either a traumatic brain injury or
an injury to the head during service. Service Members and Veterans responding yes were asked
whether they were screened at the time of the event or shortly thereafter specifically for a TBI: 19
said they had been screened, 38% of Service Members and 20% of Veterans. Most said that they
were not screened at the time or soon thereafter, 62% of Service Members and 80% of Veterans. Of
the 19 who had been screened at or around the time of the injury, 53% were screened by a doctor,
37% by a medic, and 10% by other. Of the 19 who were screened, 37% received a diagnosis of
traumatic brain injury at the time of the original screening.
27
2015
Table 4. How Respondents Connected with TBI Services
Veterans
VeteransIncarcerated
VeteransNot
Incarcerated
Service
Member
Family
Reporting
12
10
Family/ Friends
Brain Injury Association
VSO/ VSA/ VFW
Warm line or Hotline
Veterans Crisis Line
Other
18
10
14
Referral from a primary care

physician
Social Worker/ Service
Coordinator/ Counselor
Rehab Staff/ Vocational
Rehabilitation
Mental Health
The survey asked Are Service Members and Veterans getting the care they need for mental health
injuries, including Combat-related Stress? Looking at all of the Service Member, Veteran, and
Family member respondents, 63% answered No, and 37% answered Yes.
Figure 19. Are Service Members and Veterans Getting Care They Need?
Service Members
52%
Veterans
31%
Family Members
Providers
48%
69%
9%
91%
7%
93%
All
37%
0%
10%
20%
63%
30%
40%
Yes
50%
60%
70%
80%
90%
100%
No
28
2015
Many have a bad perception of the VA and many think that is the only place they can go
for health/mental health care. Provider comment
There is a severe lack of trained professionals; workforce shortage. Provider
comment
Serious lack of mental health clinicians. Provider comment
The survey asked how important a variety of services are for supporting Veterans mental health
concerns. Respondents were asked to rate each of the services with 1 meaning not at all
important and 5 meaning very important. The following figure provides an average for each
service.
4.4
3.8
3.6
3.6
4.5
4.6
4.2
4.2
4.2
4.3
3.4
3.6
4.1
4.3
3.5
4.1
3.8
4.0
3.6
3.6
4.3
4.2
4.0
3.8
3.7
Average rating
4.2
4.0
4.0
3.7
3.6
Figure 20. Rating of Services for Supporting Veterans Mental Health Concerns
SMVF ALL
Service
Veterans
Members
Counselors who have served in the military
Veterans
DOC
(Incarcerated)
Family
Members
Providers
Peer Support Groups

Veterans Services Officer (VSO) (VSA)
Civilian Couselors who received specialized training how to work with Service Members and
Veterans
Veterans Justice Officer
29
Sought care for mental health?
2015
I sought it while on active duty and

was told to go back to work. After
active duty I received mental health
support after I tried to commit
suicide!
Responding to a questions asking Veterans

whether they have sought care for mental
health, 301 Veterans answered with 46%
(n=138) responding yes. The survey logic
prompted respondents for more information
pertaining to wait time and how they connected
with services. Typically, initial appointment for
help with mental health is an assessment or
screening, followed by treatment/services.
Veterans had the following experiences:
Almost immediately = 15% (n=21)
Around a week = 13% (n=18)
Around a month = 23% (n=32)
I dont remember = 33% (n=46)
Comment = 15% (n=21)
Survey comment
Table 5. How Respondents Connected with Mental Health Services
Veterans
VeteransIncarcerated
VeteransService
Not
Family
Member
Incarcerated
Referral from a primary care

physician
45
12
33
20
Missouri Access Crisis Information
Missouri Department of Mental

health
Veterans Crisis Line
Found a counselor through online

search
VSO/ VSA
17
15
Online Search
Emergency Room or First

Responder
15
10
Other
34
14
20
11
30
2015
Those selecting Other were asked to comment further. From this we learned that six selfreferred and that 15 had referrals from family and friends, especially other friends who are
Veterans. Three mentioned the employee assistance program at work and seven more mentioned
that they sought civilian services.
Substance Use
329 respondents answered the question Have you sought care for substance use? 15% of
respondents answered that they had sought care for substance use (n=50) and of those 50, 42% are
Veterans who are incarcerated. The survey logic prompted respondents for more information
pertaining to wait time and how they connected with services. Veterans, both those involved with
the Department of Corrections and those not involved with the Department of Corrections, had the
following wait times:
Immediate = 5
Around a week = 3
Around a month = 5
I dont remember = 12
The ways that Veterans connected with substance use services varied. Most selected other and
entered their own specific comment, 80% of the comments pertained to the prison, probation and
parole, police, and courts.
Services
Respondents completed a matrix that presented a variety of services. They were asked to note if
they use the service, have used the service, need the service, or do not need the service. If they use
or have used the service, they were asked to rate it on a scale of 1 to 5 with 1 meaning it was not
helpful and 5 meaning it was very helpful. The following table presents all responses combined.
Looking broadly, the most often used service is mental health counseling with 15% of respondents
currently using it and 17% having used it in the past. The service most needed is information and
referral at 29%.
31

2015
Table 6. Services Use, Need, and Rating
Services
Assistance applying for Social Security Disability
In-home services
Continuing education
Section 8 or other housing assistance
Service coordination or case management services
Use of assistive technologies
Veterans Justice Outreach
Employment services
Recreation services
Respite care
Outpatient rehabilitation
Mental health counseling
Transportation services
Legal services
Inpatient rehabilitation
Community living skills training
Information and referral services
Support groups
Treatment for substance use
Assistance with financial management
Average
Number
Have
Do not
rating of
Need this
who have Number
used in
need this
service (1service
used this answered
the past
service
5 scale)
service
4.29
4%
15%
80%
17
315
4.20
2%
7%
90%
10
314
4.17
15%
22%
53%
78
316
4.10
2%
15%
82%
10
315
3.94
7%
17%
72%
33
314
3.90
3%
6%
87%
21
313
3.89
3%
16%
81%
9
315
3.87
12%
18%
67%
46
316
3.82
8%
19%
70%
34
314
3.75
1%
4%
94%
4
313
3.72
17%
10%
68%
67
314
3.72
17%
16%
53%
97
315
3.71
4%
10%
85%
14
314
3.69
9%
23%
67%
32
315
3.62
11%
5%
83%
39
314
3.57
2%
10%
87%
7
315
3.56
9%
29%
61%
32
315
3.50
10%
17%
70%
38
316
3.30
7%
8%
84%
23
315
3.25
5%
20%
74%
16
314
32
2015
Veterans Perspectives
In reviewing the services used and needed, it is important to keep in mind that the responses of
Veterans are from a personal perspective, and do not reflect what Veterans need in broad terms.
One in three Veterans uses or has used mental health counseling (37%) and outpatient
rehabilitation (31%). One in three Veterans has a need for legal services (32%) and information and
referral services (37%). One in four Veterans has used or uses continuing education (28%) and
employment services (22%). One in four Veterans needs continuing education (24%), recreation
services (23%) and assistance with financial management (23%). As a reflection on the age of the
Veterans, the services most not needed are in-home services (91%) and respite care (94%). The
most used and needed service is mental health counseling (54%), followed by continuing education
(52%), and information and referral services (51%).
Table 7. Veterans Perspective on Services Used and Needed (Ranked)
33
2015
Providers Perspectives
From the services providers perspective, there is not a service that is not needed. Some of the
services were outside a providers scope of work due to the specialized nature of the service. If it
was not outside the scope of work, it was either currently provided, provided in the past, or a
service to which patients/clients are referred. If it did not fit within those actions, it was needed. It
was not possible for a service to be needed and provided at the same time.
Table 8. Providers Perspective on Services Used and Needed
Services
Inpatient rehabilitation
Outpatient rehabilitation
Employment services
In-home services
Transportation services
Service coordination or case
management services
Treatment for substance use
Mental health counseling
Use of assistive technologies
Respite care
Support groups
Assistance with financial
management
Recreation services
Legal services
Section 8 or other housing
assistance
Assistance applying for
Social Security Disability
Continuing education
Community living skills
training
Information and Referral
Services
Veterans Justice Outreach
Currently
Provide
12%
31%
14%
13%
10%
Have
Provided
6%
4%
4%
9%
4%
Refer
Patients/
Clients
38%
31%
39%
33%
31%
Need
Service
7%
9%
15%
13%
20%
Do Not
Need
4%
3%
2%
4%
3%
Outside
Scope
32%
22%
26%
29%
32%
37%
47%
73%
10%
4%
20%
6%
6%
4%
3%
2%
6%
21%
26%
13%
33%
38%
32%
13%
9%
6%
17%
18%
24%
2%
1%
0%
4%
3%
1%
20%
12%
3%
33%
34%
16%
11%
12%
1%
4%
3%
1%
33%
29%
43%
22%
24%
21%
2%
1%
3%
28%
31%
31%
13%
2%
33%
14%
4%
34%
24%
15%
5%
2%
35%
31%
9%
20%
2%
2%
24%
30%
28%
4%
24%
17%
1%
26%
47%
1%
3%
1%
15%
34%
23%
24%
1%
2%
11%
37%
34
2015
Focus Group Findings

We conducted focus groups and telephone interviews throughout the state as a way of illuminating
and clarifying the results of the online survey. The focus groups and interviews also served as a
source of prioritizing information and advancing recommendations.
Two types of focus groups were held: Veterans and Providers. At the end of the online survey,
respondents were asked if they were interested in participating in a follow-up focus group. Those
who were interested were taken to a separate questionnaire to keep their survey answers
anonymous and invited to RSVP. People expressing interest who did not live near a focus group
location were contacted to participate in telephone interviews that asked the same questions as the
focus groups. In total, 37 Veterans and 26 providers participated in the focus groups or interviews.
Veterans
In the Veterans focus groups, Veterans and family members discussed how better to support
Veterans and their family members. Veterans focus groups took place in St. Louis, Columbia,
Springfield, and Kansas City.
Question: What are your barriers to seeking the care you need? What are your
recommendations for ways community-based services can ease or eliminate
barriers?
The primary barriers discussed centered around difficulties with the VA; three categories of these
barriers were identified. The first was time, with reference to the difficulty in getting appointments
at the VA, the slow process of getting referrals and other paperwork, and the inconvenient
scheduling for certain services. The second barrier was the geographic location of VA facilities and
the difficulty of travelling long distances for care, of being forced to live within a certain geographic
boundary or to pay for it out of pocket. The third barrier was the difficulty in dealing with the VA
bureaucracy and the intimidation factor in seeking to navigate this large, impersonal, government
agency. I went to the VA emergency room with 3 broken bones and they made me go to the
reception desk and update my address before they would treat me.
Another barrier was the stigma around asking for help and the fact that many Service
Members/Veterans feel (or have been told) that they should suck it up in dealing with their
routine issues and leave the limited healthcare resources for someone in more critical condition.
If community-based services could work with the VA to make healthcare and prescription services
available at non-VA locations, it would ease the time and financial burden of travel for the Service
Member/Veteran.
35
2015
Question: If you could change one thing about the health services you access,
what would it be and why?
Participants would like to see more coordination between the various agencies/departments within
the VA so that there is less delay and confusion in getting reviews or approvals. Several participants
described health-related processes that took years to achieve because of bureaucracy.
Another area where improvement is needed is in specialized training of medical staff and counselors
to work with military personnel. Some Veterans have experienced frustrating encounters with
helping professionals who had no understanding of TBI/ PTSD, of military culture, or the challenges
of re-entering civilian life.
Cost and long wait times were cited as factors that needed to change. Prescriptions at the VA are
more expensive than Medicare.
Service Members would like to seek counseling in an atmosphere of abundance, where there are
plenty of counselors available with time to talk about their issues, instead of feeling that the
counseling center is short-staffed, short of time, and only has time to deal with those who are
seriously mentally ill.
While there are many different types of community services available, most Service
Member/Veteran are confused by the numbers and the difficulty of determining what organizations
are the best fit for their needs. The clearinghouse sites are overwhelming, and most state agencies
do not advertise their services or connect with each other. For this reason, many people who have
had the experience of trying to find services wish there was a person who could guide them through
the maze of options, and perhaps even make introductions, and advocate on their behalf.
Question: According to the online survey, Service Members/Veterans are

transitioning from the military with unmet healthcare needs. From your
perspective, what can community-based services and programs do close this
gap?
The military is ineffective at preparing their people for discharge, and in teaching them how to use
post-discharge resources. Community organizations need to find ways to work around the
bureaucracy of the military. Flexibility is an important quality for organizations trying to meet the
needs of Service Members/ Veterans. Often their problems are exacerbated by the very inflexible
and slow-moving military processes (such as delayed paperwork or approvals, delayed checks,
changes in regulations, long waits for appointments, etc.) and community organizations need to be
able to fill the gaps. If you are in need, you cant wait 30 or 60 days for a board meeting to see if
you can get help.
Effective organizations reach out to the families of Service Members and offer them various types of
support services, which also opens the door to connecting with the Service Member. Key individuals
36
2015
need special training in how to provide military support and reach out to Veterans. While no one
can make another person seek help, a case manager (knowledgeable person who understands the
options) in a one-stop-shop type of situation could go a long ways toward encouraging a reluctant
Veteran to accept the help he or she needs. Ideally this person would be willing to help the client
work through the bureaucracy by making introductions, making calls on his/her behalf and setting
up appointments. The personal connection is crucial. Several participants described the
demoralizing experience of being handed a list of phone numbers and told to go find yourself some
help, when the people who are most in need of help are least capable of doing that.

transitioning from the military without information about programs and
services. What can community-based services do to close this gap?
There is a general consensus that the militarys transition program is too general to be helpful to
most Service Members re-entering civilian life. The idea (described above) for a one-stop-shop, with
a person who could provide a caring personal connection to appropriate services also applies to the
issue of information dissemination. In addition, employers, schools and other organizations likely to
work with former Service Members should consider adding or training someone to be the Veterans
representative, perhaps in the human resources department. This individual should have an
understanding of military culture and be a source of information for the Veterans, as well as a
promoter of military pride and sensitivity within the organization as a whole.
Question: Is there anything you would like to add that I have not asked?
The military is a distinct culture and current/former Service Members have unique problems and life
experiences. And while not all Veterans are alike, many of their frustrations in seeking assistance in
their post-military life are due to a lack of helping personnel who are trained to work with Veterans
or are Veterans themselves.
Providers
In the providers focus groups, community health providers and Veterans service providers
discussed how better to support Service Members through transition and Veterans and their family
members. Providers focus groups took place in St. Louis, Ft. Leonard Wood, Columbia, and Kansas
City.

transitioning from the military with unmet healthcare needs. From your
perspective, what can community-based services and programs do to close this
gap?
37
2015
Providers agreed that there needs to be a more thorough needs assessment of Service Members
when they are being processed out of the military. This is complicated because Service Members are
motivated to return home to family and friends, so it is easy to check off the box that services
were offered or not needed. The current system leaves many Service Members separated from the
military without making any real connection with anyone who can help them to navigate the
complexities of their transition, especially
when it comes to healthcare.
Additionally, providers who were also
The system is created that way so you
Veterans remembered how transition
have to advocate for yourself. They need
assistance programs provide a lot of
somebody doing outreach saying hey, do
information in a short amount of time.
you need this? or somebody saying I am
One remarked, Its like drinking out of a
ready for that need.
fire hose. Maybe some information is in
there or resources but it is real hard to
Focus group participant
retain.
Outreach is a key factor in connecting
The system is created that way so you
Service Members/Veterans with health
have to advocate for yourself. They need
care. They need to be educated in the
somebody doing outreach saying hey, do
culture of the VA healthcare system
you need this? or somebody saying I am
which is different from military culture in
ready for that need.
some important ways. Individuals have to
learn to ask questions and advocate for
themselves rather than to simply follow
orders. The system is created that way
so you have to advocate for yourself.
They need somebody doing outreach saying hey, do you need this? or somebody saying I am ready
for that need. Veterans need to be encouraged to feel that seeking help does not mean a loss of
pride, or of privacy.
Community organizations should be aware that not all branches of the military are provided with
the same information and access to healthcare. Those who served in the National Guard and the
Reserves (who may have served several tours of duty or received combat injuries) do not have the
same services available as those in the regular military. The perception that Veterans are awash in
government funded assistance needs to be altered, especially when it comes to Guard and
Reservists who will fall through the cracks without financial support to meet their health care needs.
38
2015

transitioning from the military without information about programs and
services. What can community-based services do to close this gap?
Since older or disabled Veterans may be deterred from seeking medical care from the VA because of
lack of access, community-based services could help Veterans by providing transportation or funds
for travel. As an alternative, community health providers could be trained and certified to provide
health care for Veterans.
There needs to be consistent outreach services, suitable to the needs of those needing the services.
For example, younger Service Members may be comfortable using a website, but older Veterans
might not. While there are many organizations that provide services to Veterans, a clearinghouse or
resource directory that consolidates all of the types of services in one place would help connect
individuals with the exact services they
need. However, as one provider
cautioned, online directories cannot
Online directories cannot completely
completely supplant the need for
supplant the need for individuals who get
individuals who get it and are ready to
it and are ready to help.
help.
Community organizations need to focus
on engaging with the families and helping
them to support their Service
Member/spouse. The family can be a
source of connection to and information
for the Service Member.
Question: If you could change one

thing about the health care or
other support services you
provide, what would it be and why?

Online directories cannot completely
supplant the need for individuals who get
it and are ready to help.
The top priorities for change would be more options in terms of location, treatment, scheduling, and
individualized care. Veterans seeking counseling are usually required to attend group counseling
sessions instead of/or before receiving individual counseling. This does not work for many Veterans
and they drift away from the opportunity to receive help rather than try to navigate this
uncomfortable situation. Having the ability to provide individualized counseling services would
mean that many more people receive appropriate help.
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2015
One provider summarized: They [the VA] lack flexibility and adaptability when it comes to
programming and treatment methodologies. More people could be helped if there were more
counselors and less of a one-size-fits-all approach.
Question: What have you learned that you would share with a colleague about
providing health care and other services to Service Members and Veterans?
It is important to respect the privacy of the people you are working with on a military base. There is
a perception that the commander will find out what they are talking about, and they need to know
that isnt true.
Veterans may have worked with other people who havent been effective. They may also have not
realized they had an injury or an issue immediately until it interfered with their daily life. So it may
be difficult to get to the problems.
Question: What kind of

resources or local initiatives (in
terms of products and
collaborations/networks) would
help you better meet the needs
of Service Members, Veterans,
and their families?
While some Veterans and/or Service
Members may be reluctant to ask for
help, programs designed to reach out to
their families may be a way to connect
with them. Community programs can
provide support and education to
families as they work to help their
Service Member/Veteran deal with
injuries or just integrate back into
civilian life.
Collaboration is an important piece. You

need to be talking to people who are
connected and find a way to connect to
the population you want to work with.
Collaboration is an important piece. You
need to be talking to people who are
connected and find a way to connect to
the population you want to work with.
Colleges and universities can offer specialized training to counselors and social workers for working
with military personnel that would cover issues of TBI and PTSD as well as military culture. This
could be a degree program, an emphasis area or certificate program; it might also be a course that is
taught to currently certified counselors for Continuing Education Units (CEUs).
40
2015
It is crucial for social workers and counselors to meet on a regular basis and support each other in
their efforts. Collaboration is an important piece. You need to be talking to people who are
connected and find a way to connect to the population you want to work with.
Providers in the community need to have a working knowledge of military regulations, and realize
that receiving mental health care can complicate a persons standing in the military.
Clinics and counselors could offer a sliding fee scale and evening or weekend hours to make their
services more accessible.
Having to travel long distances for medical care is a significant problem. A van or bus for
transportation to VA facilities, or travelling doctors could help with reaching more people.
Question: In what ways might you be willing to participate in local initiatives?

Participants would be willing to teach or collaborate on a class on providing services to Veterans, or
to be part of a task force. Also, it was suggested that opportunities be made more readily available
to those who want to provide volunteer help. Id like to find out about little organizations and what
they do. If I knew of someplace I could go and give some time that would be helpful to me. I want to
volunteer and I dont have any place to go.
Discussion and Implications

The discussion and implications section will present a synthesis of the data by the needs assessment
broad questions: What obstacles do Service Members, Veterans, and their families face in accessing
services? What is the current network of support available? How accessible is the network of
support? Where are there gaps in services and systems? Following the synthesis, the findings will be
compared with national-level surveys.
What obstacles do Service Members, Veterans, and their

families face in accessing services?
The first obstacle faced by Service Members transitioning from the military is a lack of health
information received at separation. Over 70% of Missouri Veterans age 25-64 left the military
without any information on traumatic brain injury. Over half of Veterans ages 25 to 44 received no
information on mental health and substance use when they transitioned from the military.
The second obstacle is that 68% of Veterans feel they left military services with untreated mental
and/or physical health issues. That is slightly inflated by the Veterans who are currently
incarcerated, 88% of which feel they left military service with untreated issues. Of Veterans who are
not incarcerated, 61% left the military with untreated health issues.
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2015
Insurance coverage may not be as great an obstacle as we thought going in to the survey. The survey
findings are inconclusive about insurance coverage as an obstacle. The focus groups, interviews, and
survey comments suggest that the bureaucracy and backlog of the VA presents obstacles to seeking
treatment, and that types of insurance do not work well together.
Health providers feel that there is a lack of knowledge of military life and culture among non-VA
providers which could pose challenges for Service Members and Veterans seeking care/treatment
from civilians. Service Members and Veterans have a different perception: 32% indicated that most
civilian health care providers were knowledgeable of military life and culture. Perhaps if not
knowledgeable, then they are respectful and supportive.
As with many things, the more one knows, the more one doesnt know: VA benefits are no
exception. Veterans, their families, and Veterans health providers spend a lot of time and energy
navigating the system. Another obstacle Service Members, Veterans, and their families face is
knowing whether, when, and how, to seek care outside of the VA. With a lack of transparency about
the process and coverage, many Veterans live with untreated mental and physical health issues.

The current network of support is complex and is highly dependent on how connected the Service
Members and Veterans are, and how motivated they are to seek treatment. This broad question
was answered mostly by the focus groups, and much time was spent describing and discussing the
complexity of benefits, services, and supports.
There is a network of support through the VA, with varying levels of satisfaction and outcomes for
Veterans.
Many Veterans and family members described connecting with case managers and/or information
and referral services as the only way they have been able to connect with the current network of
support.
Gaining access to resources and learning to be a self-advocate has been challenging for many
Veterans. This has been an essential skill in connecting with the network of support. Many Veterans
and family members learn it from friends who are Veterans, others through support providers.

Many Service Members, Veterans, and their families are navigating significant barriers to accessing
the network of support, especially when it comes to mental health, substance use, and traumatic
brain injury.
The top barriers for Veterans and their family members are stigma, geography, not knowing about
available resources, and clinic hours. The greatest difficulty with accessibility has to do with stigma,
which is also related to privacy. Veterans and family members are not only facing stigma for getting
42
2015
help, but also are facing the challenges of a diagnosis, such as having a label which they fear could
affect employment and benefits. Distance to services and supports is a concern for Veterans and
family members in rural areas. Not all of the available clinics have a full range of services offered,
which could entail driving a long distance for services. There is a lack of information about whether
it is possible to seek treatment from civilians and still have that treatment covered through VA
benefits. Lack of information is a major barrier to access.
When we asked about barriers we used the language the admission paperwork is too much
trouble. A better option would have been VA bureaucracy. From the comments and focus groups,
the bureaucracy of VA poses access challenges for Veterans.
The survey was inconclusive when it comes to accessing substance use services. Substance use could
be conflated with mental health because often substance use is part of mental health challenges.
Perhaps the term substance use should have been defined in the survey.
Where are there gaps in services and systems?

There are several poignant gaps in services and systems.
Transition. The transition assistance program offered at time of separation from the military
presents Service Members with a lot of information and the resources may not be local.
Training. Lack of trained personnel to help with Veterans-specific mental health and
behavioral health issues.
Self-advocacy and self-determination. Lack of support for Veterans to be self-advocates.
Access to information about resources and supports available, especially when it comes to
benefits.
Access to information about privacy when using mental health, behavioral health, and
traumatic brain injury resources.
Support in coping with the VA process whether through information and referral services,
case management, or a one-stop shop.
Comparison with IAVA Veterans Survey

The Iraq and Afghanistan Veterans of America (IAVA) conduct a members survey. The online needs
assessment asked a couple questions in common to compare Missouri Veterans needs with a
national picture.1
Iraq and Afghanistan Veterans of America. (2014). Member policy survey. New York City: Iraq and
Afghanistan Veterans of America. Available online: http://media.iava.org/IAVA_Member_Survey_2014.pdf
43
2015
Are Service Members and Veterans getting the care they need for
mental health injuries?
In terms of both the IAVA survey and the Missouri Needs Assessment, participants agreed that
Service Members and Veterans were not getting the care they needed in terms of mental health
injuries, including combat-related stress, and for the IAVA survey, military sexual trauma. The IAVA
survey had 67% respond that no, they dont think troops and Veterans are getting the care they
need for mental health injuries, and 63% of the Missouri Needs Assessment also responded with
no to a similar question. The IAVA survey also stated that they do not think that the Department
of Defense is doing a good job of reaching out to troops and veterans regarding their mental health
injuries and care with 60% responding no. Another 51% answered that the VA is not doing a good
job of reaching out to troops and Veterans regarding their mental health injuries and care either.
How important are each of the following for providing excellent

services for Veterans mental health concerns
Both surveys answered that counselors who have served in the military and understand the culture
are very important to providing excellent services for Veterans mental health concerns. From the
IAVA survey, 70% and 77% responded that counselors who have served in the military and
counselors who understand military life and culture is very important. The Missouri survey had
78% of respondents rank counselors who have served in the military either a 4 or a 5 on a 1 to 5
scale with 5 being very important and 1 meaning not important. The IAVA survey also had a
70% response of very important for counselors receiving specialized training on how to deal with
Service Members and Veterans.
On the IAVA survey 49% of respondents said that they had sought care for a mental health injury.
Compare this to the Missouri Survey where 56% of the total Veteran and 29% of the current Service
Member populations have sought care for mental health. In fact, nearly 68% of Service Members
and Veterans felt like the left military service with untreated mental and/or physical health issues.
Health Care
The health care that Service Members and Veterans are using seems to be a combination of military
health care, private, VA, and Medicare/Medicaid. The Missouri survey found that 46% were using
TRICARE. When looking at Veterans specifically 47% were using V.A. Health care and 31% were
using private insurance with only 24% using TRICARE. Many of the Veterans and Service Members in
the Missouri data reported using multiple insurance providers. The IAVA survey found that 24% of
participants were using Military health care exclusively. VA healthcare and private insurance each
had 21% of the survey population using these providers exclusively. 14% were using the VA
healthcare plan supplemented by private insurance.
44
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Suicide
When asked to rank a set of 12 issues in order of importance, Iraq and Afghanistan veterans ranked:
1
2
3
4
5
6
7
8
9
10
11
12
Employment and Jobs

Mental Health
Disability Benefits (VA Backlog)
Health Care
Education and GI Bill
Suicide
Families
Homelessness
Retirement
Housing
Military Salaries
Womens Issues
Suicide at number 6 has become an urgent issues among Veterans as invisible wounds of the war.
37% of the IAVA survey respondents said that they have known someone who has committed
suicide either separated from the service or still actively on duty.
Suggested Next Steps

The Missouri Behavioral Health Alliance and the Missouri Traumatic Brain Injury Partnership should
review these findings. We are available to discuss the data in further detail to help both entities use
the needs assessment for planning purposes.
Suggested Priority Areas for Action
Offer continuing education courses on military culture for civilian service providers.
Offer continuing education courses on how to support Veterans in accessing services from
the VA to civilian service providers and family members.
Research and provide resources on traumatic brain injury to service providers to increase
familiarity with the screening process, how TBI effects behavior, treatment process, and
survivor resources.
Local communities could offer transition support to Veterans and family members either
returning home or relocating. These resources would be at the very local level to support
the transition process and help welcome Veterans and families.
Help Veterans connect with local, specific online resources for behavioral health that helps
retain privacy and connects Veterans needing help with well-trained, resourceful people.
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Appendices
Appendix A: Focus Group Scripts
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Appendix B: Online Survey
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55
Address: 215 W. Pershing Road, 5th Floor, Kansas

City, Missouri 64108
Telephone: 816.235.5872
Website: www.ihd.umkc.edu
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MISSOURI MILITARY

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

By Alexis Petri, Ed.D. and Ryan Gee, M.A.

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

General Leonard Wood Community Hospital TBI Program

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

What is the current network of support available?

How accessible is the network of support?

Where are there gaps in services and

A total of 475 people completed the online survey:

Figure ES1. Survey Respondents

Figure ES1. Survey Respondents

Current Service Members

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

18-24 years old

25-44 years old

18-24 years old

25-44 years old

45-64 years old

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Insurance and Health Providers

V.A. Health Care

Service Member (n=118)

Family Members of Veterans

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Barriers to Health Services

Traumatic Brain Injury

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Suggested Priority Areas for Action

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

What is the current network of support available?

How accessible is the network of support?

Where are there gaps in services and systems?

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Veterans Profile in Missouri

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Characteristics of Survey Participants

Figure 2. Survey Respondents by Role Service Members,

Service Members, Veterans,

Current Service Members

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

92% of Service Members and

SERVICE MEMBER, VETERAN, FAMILY MEMBER PARTICIPANTS, BY AGE & GENDER

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Table 2. Survey Respondents by Ethnicity and Race

Table 3. Comparison by Age with Other Data Sources

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Doctor Mental Health

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

Figure 5. Estimated Number of Iraq/Afghanistan

Figure 6. Veterans and Family Members by Zip

Figure 7. Providers by Zip Code

MISSOURI MILITARY COMMUNITY HEALTH NEEDS ASSESSMENT

18-24 years old

25-44 years old

45-64 years old

2 per. Mov. Avg. (25-44 years old)