Vexed Veterans: The Continuum of Care in the VA

On January 6th, 2016 outrage ensued across the nation as Esteban Santiago-Ruiz, a military veteran with a history of mental health issues, opened fire on innocent travelers in Fort Lauderdale-Hollywood International Airport. Shortly after the shooting, Florida Governor Rick Scott labeled the incident a ‘senseless act of evil.’ Yet, is it that simple? Was this simply a random act of evil or another unfortunate event stemming from a much larger issue? Should the American public support the execution of this troubled man? Or, should the American public take a moment and ask why veterans are more prone to act out violently?

The effectiveness of preventing acts of violence by means of execution or imprisonment is up for debate, but is no doubt a short-term solution. Moreover, the Veteran’s Health Administration (VA) has faced intense public scrutiny in recent years; the 2014 Phoenix facility scandal being the catalyst for uncovering widespread corruption and incompetence. Perhaps then, it is time to reevaluate the VA’s ability to implement effective means of long-term care for veterans suffering with mental and behavioral health illness.

However, before any solution can be brought to the table, it is first necessary to determine the origins of this melancholy event. In order to gain more knowledgeable insight on this topic, Meta interviewed a military veteran who wishes to remain anonymous. The following conversation highlights struggles of transitioning veterans and discusses strategies that may improve the continuum of care within the VA.

Q: If you were in a position to prevent another incident like Ft. Lauderdale, what would you do or change about the VA?

A: First, I would just like to say the VA has excellent programs like free healthcare, free education, financial compensation, therapy, and employment opportunities. I was able to get a college degree because of the VA. But there is definitely room for improvement. There should be a serious effort to establish more accessible care. Local VA facilities like VA urgent care centers or VA walk in clinics should be established rather than have one hospital that might be 40, 50, or more miles away. Second, and more importantly, the VA needs to take a stronger stance on educating returning veterans and their families. It should be mandatory for the VA to register returning veterans so they can quickly reach out and discuss the programs they offer, where you can seek help, etc. Many veterans don’t seek help because they simply feel as if no one cares, or they don’t matter to our society, or don’t know what kind of help is available. If you don’t make an effort to seek help, then you will never get it. A simple phone call from a VA physician or employee, a call that veterans usually never get, can, in my opinion, make a big difference.

Q: Were you contacted by the VA when you arrived home?

A: No. I was home for 5 months and was never contacted by anyone from the VA. It was not until a friend finally convinced me to visit my closest facility that I spoke with someone from the VA. If I had not made the effort to go, I don’t think I would have ever been contacted.

Q: Do you think the VA failed Esteban in this manner?

A: It was not just the VA. Many channels failed. His family noticed his behavioral changes when he came home and that should have been the first red flag. In his mind he was, what we call ‘down range’, or still back in Iraq or Afghanistan. He went to the FBI and sought help, who then washed their hands and turned him over to the local police because he apparently did not present any serious issues, even after admitting to hearing voices and other things that should have been taken as serious red flags. This man sought help and it should have been followed all the way through, from the FBI, to the local police, to his local VA facility. Once his local VA facility learned of the situation, they should have reached out to him and continued to keep tabs on him. I don’t know if they did or didn’t, but this is where we must improve. Getting veterans to seek care is hard enough so when a veteran actually seeks care because they know things aren’t right you can’t let them slip through the cracks.

Q: Do you think this is a method the VA can use to bring about a more effective continuum of care?

A: Yes. The VA can improve long-term care by establishing a serious outreach community and culture. Did the FBI or police contact his local VA facility and warn them of his condition? I don’t know, but if they did, did the VA contact Esteban and ask him to come in for an evaluation? Did anybody contact his family to see how he was doing or to educate them on VA services? Did anybody check with him after he got his weapon back or call him to just see how he’s doing, or if he needed help? These are the questions we need to start asking. It is very easy for someone to slip through the cracks if nobody is keeping tabs or showing concern. Beyond follow up appointments or getting back lab or test results, you typically don’t hear from anybody in the VA. It seems like nobody learns their lessons or is held accountable, or updates policies to handle these situations that present similar red flags. They often wash their hands and move on. The VA ought to update their standard procedures or protocols to meet this type of persistent outreach.

This conversation of course does not reflect the experiences of every veteran. As stated above, the VA provides excellent services that benefits thousands of veterans throughout their transition process. However, as our conversation ended it became more apparent Esteban, a mentally disturbed man who sacrificed his life to serve our country, possibly faces execution; likely due to the lack of proper care, education, and outreach. Not necessarily because he was an incarnation of evil. Yet, there may be solutions to prevent further acts of violence.

Firstly, the VA can be localized to meet needs of veteran communities. Integrating urgent care centers or walk in clinics with VA physicians and services can be an incentive for veterans to seek care who currently have to drive hours or across state boarders. Secondly, the establishment of serious and persistent outreach may prove effective. In fact, the VA has cited studies in suicide prevention which support this notion. Indeed, a 2009 report titled Strategies for Suicide Prevention in Veterans cited a study in which two groups of patients, one controlled and one experimental, were seen in a Pittsburgh hospital. The study reveals, after discharge,

“Patients were in contact with staff at least biweekly to provide treatment, or to monitor the treatment when it was provided by other services. Patients assigned to the control group were treated in the usual manner in the ER or hospital, and released with written appointments; no attempts were made to provide outreach to those who failed to follow up. The outcome was the number of suicide reattempts in the 4 month follow up period. The treatment group had 4.8% reattempt rate, while the control group had a 15.8% reattempt rate, a statistically significant difference” (Shekelle, Bagley, Munjas 20).

In the same report, a study conducted in San Francisco on patients admitted to psychiatric hospitals for depression and violent outbreaks bare significant similarities to the previous study. Indeed, the results reveal,

“Patients in the contact group received short, personalized letters from staff who had conducted their initial interviews expressing concern about the patient, and inviting the patient to respond. Patients in the no-contact group and those who had complied with the initial post-discharge therapy received no letters. In five years after the index contact, the treatment (contact) group had a suicide rate of 3.9% compared to the control (no-contact) group at 4.6%” (Shekelle, Bagley, Munjas 24).

It is difficult to determine whether civilian based strategies will have the same effect on military veterans, whose life experiences are drastically different. However, if the VA is aware of these benefits, have they taken necessary measures to implement wide scale outreach programs?  If not, perhaps the VA can invest in outreach methodologies such as registering and contacting returning veterans to schedule evaluations and discuss different pathways of care, as the interviewee suggests. From there, the VA can improve long-term outreach efforts with their patients to accurately determine the next steps of care, if needed. This experiment may produce similar results from the studies above and, in turn, reduce violence among veterans and ultimately improve the VA’s continuum of care. These simple strategies can bring a glimmer of hope to veterans who feel they don’t matter to society or don’t know if they should seek care. In some cases, a simple glimmer of hope may have a significant impact. Although establishing local VA facilities and providing persistent outreach will not solve every issue within the VA, it apparently continues to be an overlooked, but obvious starting point.




Bowman, Dan. “Lawmakers Approve $260M for VistA Modernization, but Demand Interoperability With DOD.” FierceHealthcare, Mar. 28th, 2016.

Shekelle, Paul MD., Bagley Steven MD, MS., Munjas, Brett BA. “Strategies for Suicide Prevention in Veterans.” Department of Veterans Affairs Health Services Research & Development Service, January 2009.

Interview with: Anonymous Military Veteran. January 10th, 2016.

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