Federal Practitioner

Since 2007, Primary Care Mental Health Integration (PCMHI) at the Veterans Health Administration (VHA) has improved access to mental health care services for veterans by directly embedding mental health care professionals (HCPs) within primary care teams.¹ Veterans referred to PCMHI often have co-occurring physical and mental health disorders.² Untreated chronic physical and mental comorbidities can diminish the effectiveness of medical and mental health interventions. Growing evidence suggests that treatment of mental health conditions can improve physical health outcomes and management of physical conditions can improve mental health outcomes.^2,3

Chronic pain and sleep disorders are common reasons patients present to primary care, and often coexist together with mental health comorbidities.⁴ Sleep disorders affect 50% to 88% of patients with chronic pain, and 40% of patients with sleep disorders report chronic pain.⁴ Research has found that chronic pain and sleep disorders increase the risk of suicide attempts and deaths by suicide. Addressing suicide prevention simultaneously with treating chronic pain and insomnia is encouraged.⁵

Background

PCMHI treats physical and mental health comorbidities with a collaborative framework and a biopsychosocial integrative model.⁶ PCMHI staff provide mental health services as members of primary care teams. An interdisciplinary PCMHI team can include, but is not limited to, psychologists, mental health social workers, psychiatrists, nurse practitioners, clinical pharmacists, and mental health nurses. Quality of care within this model is elevated, as mental and physical health are recognized as interconnected. Collaboration between primary care and mental health benefits veterans and the VHA by increasing access to mental health care, decreasing stigma associated with mental health treatment, improving health outcomes, and enhancing the likelihood of recovery, resulting in high patient satisfaction.^6-8

In the existing PCMHI model, HCPs are encouraged to use short-term, evidence-based psychotherapies (EBPs).⁹ Veterans referred to PCMHI from primary care are typically able to attend 1 to 6 brief sessions of mental health treatment, often 20 to 30 minutes long. Most EBPs in PCMHI are disorder- specific, providing interventions focused on a single presenting problem (eg, insomnia, chronic pain, or posttraumatic stress disorder [PTSD]). For veterans with a single issue, this model can be very effective. ^1,10 However, the high rate of co-occurrence of mental and physical health issues can make it difficult to fully treat interrelated problems if the focus is on 1 specific diagnosis. Veterans with a need for additional (more comprehensive or intensive) mental health treatment are frequently referred to a higher, more resource-intensive level of mental health care, either in the VHA or the community. Examples of higher levels of mental health care include the longer term behavioral health interdisciplinary program (BHIP), sometimes called a mental health clinic (MHC), or a specialty mental health program such as a PTSD clinic.

As PCMHI continues to grow, new challenges have emerged related to staffing shortages and gaps in the clinical delivery of mental health treatment within the VHA. At the same time, demand for VHA mental health treatment has increased. However, a mental health professional shortage severely limits the ability of the VHA to meet this demand. In many systems, this shortage may result in more referrals being made to a higher level of mental health care because of fewer resources to provide comprehensive treatment in a less intensive PCMHI setting.^8,10,11 This referral pattern can overburden higher level care, often with long wait times for treatment and lengthy lag times between appointments. Furthermore, these gaps in the clinical delivery of care cannot be effectively addressed by hiring additional mental health professionals. This strain on resources can impede access to care and negatively affect outcomes.¹⁰

Recent congressional reports highlight these issues, noting that demand for mental health services continues to outpace the capacity of both PCMHI and higher levels of mental health care, leading to delays in treatment that may negatively affect outcomes.^8,10,11 These delays can be particularly detrimental for individuals with conditions requiring timely intervention.^8,11 Some veterans are willing to engage with PCMHI in a primary care setting but may be reluctant to engage in general mental health treatment. These veterans might not receive the mental health care they need without PCMHI.

Group Psychotherapy

A group psychotherapy format can address gaps in care delivery and provide advantages for patients, mental health professionals, and the VHA. Group psychotherapy aligns with the US Department of Veterans Affairs (VA) 2018 Blueprint for Excellence and 2018 to 2024 strategic plan, underscoring the need for more timely and efficient mental health services.^12,13

Benefits of group psychotherapy include reductions in symptoms, decreased feelings of isolation, increased social support, decreased emotional suppression, and enhanced satisfaction with overall quality of life.^14-17 Studies of veterans with PTSD have found less attrition among those who chose group therapy compared with individual therapy.^14,18 Group psychotherapy improves access to care by enabling delivery to more patients.¹⁴ When compared with individual therapy, the group format allows for a large number of patients to be treated simultaneously, maximizing resources and reducing costs.^3,19-21

VISN 9 CRH Innovation

The VA provides care to veterans through regionally distinct administrative systems known as Veterans Integrated Service Networks (VISNs). Clinical resource hubs (CRH) are VISN-based programs created to cover VA staffing shortages by virtually deploying HCPs into local VA systems until vacancies are filled. The national CRH vision of effectively using resources and innovative technologies to meet veterans’ health care needs, along with the above-referenced clinical gaps in the delivery of care, inspired the development of VIP Boot Camp within the VISN 9 CRH.²²

Program Description

VIP Boot Camp is an evidence-informed group psychotherapy program designed to provide timely, brief, and comprehensive mental health treatment for veterans. VIP Boot Camp was developed to address the needs of veterans accessing PCMHI services who experience ≥ 1 of the often overlapping problems of anxiety/emotion regulation/stress, sleep difficulties, and chronic pain (Figure). VIP Boot Camp uses an integrative approach to highlight interconnections and similarities among these difficulties and their treatment. A primary vision of the program is to provide this comprehensive treatment within PCMHI (upstream) so additional referrals to higher levels of mental health care (downstream) may not be needed.

This design is intentional because it increases the number of individuals who can be treated upstream with comprehensive, preventive, and proactive care within PCMHI which, over time, frees up resources in the BHIP for individuals requiring higher levels of care. This approach also aligns with the importance of early treatment for chronic pain and sleep disturbances, which are linked to increased risk of suicide attempts and deaths by suicide for veterans.⁵ National interest for VIP Boot Camp grew during fiscal year 2024 after it received the Gold Medal Recognition for Most Adoptable and Greatest Potential for Impact during VHA National Access Sprint Wave 3—Mental Health Call of Champions.

History

VIP Boot Camp began in August 2021 at VISN 9 as a 6-week virtual group for veterans with chronic pain. It was established to assist a large VA medical center experiencing PCMHI staffing shortages and lacking available PCMHI groups. Many veterans in the chronic pain group discussed co-occurring issues such as sleep disturbances, anxiety, and stress. The CRH team considered launching 2 separate groups to address these additional PCMHI-level issues; however, in developing the group material which drew from multiple clinical approaches, the team recognized significant overlapping and interconnected themes.

The team discussed EBPs within the VHA and how certain interventions within these treatments could be helpful across many other co-occurring disorders. Integrated tactics (clinical interventions) were drawn from cognitive-behavioral therapy (for depression, insomnia, or chronic pain), acceptance and commitment therapy, prolonged exposure, cognitive processing therapy, dialectical behavior therapy, unified protocol, pain reprocessing therapy, emotional awareness and expression therapy, interpersonal neurobiology, and mindfulness. We collaborated with veterans during VIP Boot Camp groups to determine how to present and discuss complex interventions in ways that were clinically accurate, understandable, relatable, and relevant to their experiences.

To address accessibility issues, the chronic pain group was reduced to 4 weeks. A second 4-week module for anxiety, emotion regulation, and stress was developed, mirroring the tactics, language, and integrative approach of the revised chronic pain module. A similar integrative approach led to the development of the third and final 4-week module for sleep disturbances.

Current Program

The VIP Boot Camp consists of three 4-week integrated modules, each highlighting a critical area: sleep disturbances (Improving Sleep), chronic pain difficulties (Outsmarting Chronic Pain), and emotion regulation difficulties (Rewiring Your Brain). VIP Boot Camp is designed for veterans who are at the PCMHI level of care. Referrals are accepted for patients receiving treatment from primary care or PCMHI.

Guidelines for participation in VIP Boot Camp may differ across sites or VISNs. For example, a veteran who has been referred to the BHIP for medication management only or to a specialty MHC such as a pain clinic or PTSD clinic might also be appropriate and eligible for VIP Boot Camp.

Given the interconnectedness of foundational themes, elements, and practices across the VIP Boot Camp modules, the modules are offered in a rolling format with a veteran-centric “choose your own adventure” approach. Tactics are presented in the modules in a way that allows patients to begin with any 1 of the 3 modules and receive treatment that will help in the other areas. Participants choose their core module and initial treatment focus based on their values, needs, and goals. Individuals who complete a core module can end their VIP Boot Camp experience or continue to the next 4-week module for up to 3 modules.

The group is open to new individuals at the start of any 4-week module and closed for the remainder of its 4-week duration. This innovative rolling modular approach combines elements of open- and closed-group format, allowing for the flexibility and accessibility of an open group with the stability and peer support of a closed group.

Given the complicated and overlapping nature of chronic pain, emotion regulation/ stress, and sleep disturbances, VIP Boot Camp acknowledges that everything is interconnected and difficulties in 1 area may impact other areas. The 3 interconnected modules with repeating themes provide coherence and consistency. Veterans learn how interconnections across difficulties can be leveraged so that tactics learned and practiced in 1 area can assist in other areas, changing the cycle of suffering into a cycle of growth.

VIP Boot Camp sessions are 90 minutes long, once weekly for 4 weeks, with 2 mental health professionals trained to lead a dynamic group psychotherapy experience that aims to be fun for participants. VIP Boot Camp synthesizes evidence-based and evidence-informed interventions, as well as techniques from VHA complementary and integrative health programs, psychoeducation, and interpersonal interventions that model connection, playfulness, and healthy boundaries. These varied strategies combine to equip veterans with practical tactics for self-management outside of sessions, a process described as “finding puzzle pieces.” VIP Boot Camp is built on the idea that people are more likely to adopt and practice any tactic after being taught why that tactic is important, and how it fits into their larger interconnected puzzle. After each session, participants are provided with additional asynchronous educational material to help reinforce their learnings and practices.

Although individuals may hesitate to participate in a group setting, they often find the experience of community enhances and accelerates their treatment and gains. This involvement is highlighted in a core aspect of a VIP Boot Camp session called wins, during which participants learn how others on their Boot Camp team are implementing new skills and moving toward their personal values and objectives in a stepwise manner. Through these shared experiences, veterans discover how tactics working for others may serve as a model for their own personal objectives and plans for practice. The sense of relief described by many upon realizing they are not alone in their experiences, along with the satisfaction felt in discovering their ability to support others in Boot Camp, is described by many participants as deeply meaningful and in line with their personal values.

While developed as a fully virtual group program, VIP Boot Camp can also be conducted in person. The virtual program has been successful and continues to spread across VISN 9. There are 8 virtual VIP Boot Camps running in VISN 9, with plans for continued expansion. In the VISN 9 CRH, Boot Camps typically have 10 to 12 participants. Additionally, as VIP Boot Camp grows within a location there are frequently sufficient referrals to support a second rolling group, which enables staggering of the module offerings to allow for even more timely treatment.

Training Program

VISN 9 CRH also developed a VIP Boot Camp 3-day intensive training program for PCMHI HCPs that consists of learning and practicing VIP Boot Camp material for chronic pain, emotion regulation/ stress, sleep disturbances, mindfulness, and guided imagery, along with gaining experience as a VIP Boot Camp coleader. Feedback received from PCMHI HCPs who completed training has been positive. There is also a private Microsoft Teams channel for HCPs, which allows for resource sharing and community building among coleaders. More than 75 PCMHI HCPs have completed VIP Boot Camp training and > 25 VIP Boot Camps have been established at 4 additional VISNs.

The VISN 9 CRH VIP Boot Camp program initiated an implementation and effectiveness project with the Michael E. DeBakey VA Medical Center and the South Central Mental Illness Research, Education and Clinical Center. The focus of this collaboration is support for implementation and treatment effectiveness research with reports, articles, and a white paper on findings and best practices, alongside continued dissemination of the VIP Boot Camp program and training.

Conclusions

VIP Boot Camp is a PCMHI group program offering readily available, comprehensive, and integrative group psychotherapy services to veterans experiencing . 1 of the following: chronic pain, emotion regulation/ stress, and sleep disturbances. It was launched at the VISN 9 CRH with a goal of addressing clinical gaps in the delivery of mental health care, by increasing the number of patients treated within PCMHI. The VIP Boot Camp model provides veterans the opportunity to transform cycles of suffering into cycles of growth through a single approach that can address multiple presenting and interconnected issues.

A 3-day VIP Boot Camp training program provides a quick and effective path for a PCMHI program to train HCPs to launch a VIP Boot Camp. The VISN 9 CRH will continue to champion VIP Boot Camp as a model for the successful provision of comprehensive and integrative mental health treatment within PCMHI at the VA. Through readily available access to comprehensive mental health treatment in an environment that promotes participant empowerment and social engagement, VIP Boot Camp represents an integrative and innovative model of mental health treatment that offers benefits to veteran participants, HCPs, and the VHA.

Since 2007, Primary Care Mental Health Integration (PCMHI) at the Veterans Health Administration (VHA) has improved access to mental health care services for veterans by directly embedding mental health care professionals (HCPs) within primary care teams.¹ Veterans referred to PCMHI often have co-occurring physical and mental health disorders.² Untreated chronic physical and mental comorbidities can diminish the effectiveness of medical and mental health interventions. Growing evidence suggests that treatment of mental health conditions can improve physical health outcomes and management of physical conditions can improve mental health outcomes.^2,3

Chronic pain and sleep disorders are common reasons patients present to primary care, and often coexist together with mental health comorbidities.⁴ Sleep disorders affect 50% to 88% of patients with chronic pain, and 40% of patients with sleep disorders report chronic pain.⁴ Research has found that chronic pain and sleep disorders increase the risk of suicide attempts and deaths by suicide. Addressing suicide prevention simultaneously with treating chronic pain and insomnia is encouraged.⁵

Background

PCMHI treats physical and mental health comorbidities with a collaborative framework and a biopsychosocial integrative model.⁶ PCMHI staff provide mental health services as members of primary care teams. An interdisciplinary PCMHI team can include, but is not limited to, psychologists, mental health social workers, psychiatrists, nurse practitioners, clinical pharmacists, and mental health nurses. Quality of care within this model is elevated, as mental and physical health are recognized as interconnected. Collaboration between primary care and mental health benefits veterans and the VHA by increasing access to mental health care, decreasing stigma associated with mental health treatment, improving health outcomes, and enhancing the likelihood of recovery, resulting in high patient satisfaction.^6-8

In the existing PCMHI model, HCPs are encouraged to use short-term, evidence-based psychotherapies (EBPs).⁹ Veterans referred to PCMHI from primary care are typically able to attend 1 to 6 brief sessions of mental health treatment, often 20 to 30 minutes long. Most EBPs in PCMHI are disorder- specific, providing interventions focused on a single presenting problem (eg, insomnia, chronic pain, or posttraumatic stress disorder [PTSD]). For veterans with a single issue, this model can be very effective. ^1,10 However, the high rate of co-occurrence of mental and physical health issues can make it difficult to fully treat interrelated problems if the focus is on 1 specific diagnosis. Veterans with a need for additional (more comprehensive or intensive) mental health treatment are frequently referred to a higher, more resource-intensive level of mental health care, either in the VHA or the community. Examples of higher levels of mental health care include the longer term behavioral health interdisciplinary program (BHIP), sometimes called a mental health clinic (MHC), or a specialty mental health program such as a PTSD clinic.

As PCMHI continues to grow, new challenges have emerged related to staffing shortages and gaps in the clinical delivery of mental health treatment within the VHA. At the same time, demand for VHA mental health treatment has increased. However, a mental health professional shortage severely limits the ability of the VHA to meet this demand. In many systems, this shortage may result in more referrals being made to a higher level of mental health care because of fewer resources to provide comprehensive treatment in a less intensive PCMHI setting.^8,10,11 This referral pattern can overburden higher level care, often with long wait times for treatment and lengthy lag times between appointments. Furthermore, these gaps in the clinical delivery of care cannot be effectively addressed by hiring additional mental health professionals. This strain on resources can impede access to care and negatively affect outcomes.¹⁰

Recent congressional reports highlight these issues, noting that demand for mental health services continues to outpace the capacity of both PCMHI and higher levels of mental health care, leading to delays in treatment that may negatively affect outcomes.^8,10,11 These delays can be particularly detrimental for individuals with conditions requiring timely intervention.^8,11 Some veterans are willing to engage with PCMHI in a primary care setting but may be reluctant to engage in general mental health treatment. These veterans might not receive the mental health care they need without PCMHI.

Group Psychotherapy

A group psychotherapy format can address gaps in care delivery and provide advantages for patients, mental health professionals, and the VHA. Group psychotherapy aligns with the US Department of Veterans Affairs (VA) 2018 Blueprint for Excellence and 2018 to 2024 strategic plan, underscoring the need for more timely and efficient mental health services.^12,13

Benefits of group psychotherapy include reductions in symptoms, decreased feelings of isolation, increased social support, decreased emotional suppression, and enhanced satisfaction with overall quality of life.^14-17 Studies of veterans with PTSD have found less attrition among those who chose group therapy compared with individual therapy.^14,18 Group psychotherapy improves access to care by enabling delivery to more patients.¹⁴ When compared with individual therapy, the group format allows for a large number of patients to be treated simultaneously, maximizing resources and reducing costs.^3,19-21

VISN 9 CRH Innovation

The VA provides care to veterans through regionally distinct administrative systems known as Veterans Integrated Service Networks (VISNs). Clinical resource hubs (CRH) are VISN-based programs created to cover VA staffing shortages by virtually deploying HCPs into local VA systems until vacancies are filled. The national CRH vision of effectively using resources and innovative technologies to meet veterans’ health care needs, along with the above-referenced clinical gaps in the delivery of care, inspired the development of VIP Boot Camp within the VISN 9 CRH.²²

Program Description

VIP Boot Camp is an evidence-informed group psychotherapy program designed to provide timely, brief, and comprehensive mental health treatment for veterans. VIP Boot Camp was developed to address the needs of veterans accessing PCMHI services who experience ≥ 1 of the often overlapping problems of anxiety/emotion regulation/stress, sleep difficulties, and chronic pain (Figure). VIP Boot Camp uses an integrative approach to highlight interconnections and similarities among these difficulties and their treatment. A primary vision of the program is to provide this comprehensive treatment within PCMHI (upstream) so additional referrals to higher levels of mental health care (downstream) may not be needed.

This design is intentional because it increases the number of individuals who can be treated upstream with comprehensive, preventive, and proactive care within PCMHI which, over time, frees up resources in the BHIP for individuals requiring higher levels of care. This approach also aligns with the importance of early treatment for chronic pain and sleep disturbances, which are linked to increased risk of suicide attempts and deaths by suicide for veterans.⁵ National interest for VIP Boot Camp grew during fiscal year 2024 after it received the Gold Medal Recognition for Most Adoptable and Greatest Potential for Impact during VHA National Access Sprint Wave 3—Mental Health Call of Champions.

History

VIP Boot Camp began in August 2021 at VISN 9 as a 6-week virtual group for veterans with chronic pain. It was established to assist a large VA medical center experiencing PCMHI staffing shortages and lacking available PCMHI groups. Many veterans in the chronic pain group discussed co-occurring issues such as sleep disturbances, anxiety, and stress. The CRH team considered launching 2 separate groups to address these additional PCMHI-level issues; however, in developing the group material which drew from multiple clinical approaches, the team recognized significant overlapping and interconnected themes.

The team discussed EBPs within the VHA and how certain interventions within these treatments could be helpful across many other co-occurring disorders. Integrated tactics (clinical interventions) were drawn from cognitive-behavioral therapy (for depression, insomnia, or chronic pain), acceptance and commitment therapy, prolonged exposure, cognitive processing therapy, dialectical behavior therapy, unified protocol, pain reprocessing therapy, emotional awareness and expression therapy, interpersonal neurobiology, and mindfulness. We collaborated with veterans during VIP Boot Camp groups to determine how to present and discuss complex interventions in ways that were clinically accurate, understandable, relatable, and relevant to their experiences.

To address accessibility issues, the chronic pain group was reduced to 4 weeks. A second 4-week module for anxiety, emotion regulation, and stress was developed, mirroring the tactics, language, and integrative approach of the revised chronic pain module. A similar integrative approach led to the development of the third and final 4-week module for sleep disturbances.

Current Program

The VIP Boot Camp consists of three 4-week integrated modules, each highlighting a critical area: sleep disturbances (Improving Sleep), chronic pain difficulties (Outsmarting Chronic Pain), and emotion regulation difficulties (Rewiring Your Brain). VIP Boot Camp is designed for veterans who are at the PCMHI level of care. Referrals are accepted for patients receiving treatment from primary care or PCMHI.

Guidelines for participation in VIP Boot Camp may differ across sites or VISNs. For example, a veteran who has been referred to the BHIP for medication management only or to a specialty MHC such as a pain clinic or PTSD clinic might also be appropriate and eligible for VIP Boot Camp.

Given the interconnectedness of foundational themes, elements, and practices across the VIP Boot Camp modules, the modules are offered in a rolling format with a veteran-centric “choose your own adventure” approach. Tactics are presented in the modules in a way that allows patients to begin with any 1 of the 3 modules and receive treatment that will help in the other areas. Participants choose their core module and initial treatment focus based on their values, needs, and goals. Individuals who complete a core module can end their VIP Boot Camp experience or continue to the next 4-week module for up to 3 modules.

The group is open to new individuals at the start of any 4-week module and closed for the remainder of its 4-week duration. This innovative rolling modular approach combines elements of open- and closed-group format, allowing for the flexibility and accessibility of an open group with the stability and peer support of a closed group.

Given the complicated and overlapping nature of chronic pain, emotion regulation/ stress, and sleep disturbances, VIP Boot Camp acknowledges that everything is interconnected and difficulties in 1 area may impact other areas. The 3 interconnected modules with repeating themes provide coherence and consistency. Veterans learn how interconnections across difficulties can be leveraged so that tactics learned and practiced in 1 area can assist in other areas, changing the cycle of suffering into a cycle of growth.

VIP Boot Camp sessions are 90 minutes long, once weekly for 4 weeks, with 2 mental health professionals trained to lead a dynamic group psychotherapy experience that aims to be fun for participants. VIP Boot Camp synthesizes evidence-based and evidence-informed interventions, as well as techniques from VHA complementary and integrative health programs, psychoeducation, and interpersonal interventions that model connection, playfulness, and healthy boundaries. These varied strategies combine to equip veterans with practical tactics for self-management outside of sessions, a process described as “finding puzzle pieces.” VIP Boot Camp is built on the idea that people are more likely to adopt and practice any tactic after being taught why that tactic is important, and how it fits into their larger interconnected puzzle. After each session, participants are provided with additional asynchronous educational material to help reinforce their learnings and practices.

Although individuals may hesitate to participate in a group setting, they often find the experience of community enhances and accelerates their treatment and gains. This involvement is highlighted in a core aspect of a VIP Boot Camp session called wins, during which participants learn how others on their Boot Camp team are implementing new skills and moving toward their personal values and objectives in a stepwise manner. Through these shared experiences, veterans discover how tactics working for others may serve as a model for their own personal objectives and plans for practice. The sense of relief described by many upon realizing they are not alone in their experiences, along with the satisfaction felt in discovering their ability to support others in Boot Camp, is described by many participants as deeply meaningful and in line with their personal values.

While developed as a fully virtual group program, VIP Boot Camp can also be conducted in person. The virtual program has been successful and continues to spread across VISN 9. There are 8 virtual VIP Boot Camps running in VISN 9, with plans for continued expansion. In the VISN 9 CRH, Boot Camps typically have 10 to 12 participants. Additionally, as VIP Boot Camp grows within a location there are frequently sufficient referrals to support a second rolling group, which enables staggering of the module offerings to allow for even more timely treatment.

Training Program

VISN 9 CRH also developed a VIP Boot Camp 3-day intensive training program for PCMHI HCPs that consists of learning and practicing VIP Boot Camp material for chronic pain, emotion regulation/ stress, sleep disturbances, mindfulness, and guided imagery, along with gaining experience as a VIP Boot Camp coleader. Feedback received from PCMHI HCPs who completed training has been positive. There is also a private Microsoft Teams channel for HCPs, which allows for resource sharing and community building among coleaders. More than 75 PCMHI HCPs have completed VIP Boot Camp training and > 25 VIP Boot Camps have been established at 4 additional VISNs.

The VISN 9 CRH VIP Boot Camp program initiated an implementation and effectiveness project with the Michael E. DeBakey VA Medical Center and the South Central Mental Illness Research, Education and Clinical Center. The focus of this collaboration is support for implementation and treatment effectiveness research with reports, articles, and a white paper on findings and best practices, alongside continued dissemination of the VIP Boot Camp program and training.

Conclusions

VIP Boot Camp is a PCMHI group program offering readily available, comprehensive, and integrative group psychotherapy services to veterans experiencing . 1 of the following: chronic pain, emotion regulation/ stress, and sleep disturbances. It was launched at the VISN 9 CRH with a goal of addressing clinical gaps in the delivery of mental health care, by increasing the number of patients treated within PCMHI. The VIP Boot Camp model provides veterans the opportunity to transform cycles of suffering into cycles of growth through a single approach that can address multiple presenting and interconnected issues.

A 3-day VIP Boot Camp training program provides a quick and effective path for a PCMHI program to train HCPs to launch a VIP Boot Camp. The VISN 9 CRH will continue to champion VIP Boot Camp as a model for the successful provision of comprehensive and integrative mental health treatment within PCMHI at the VA. Through readily available access to comprehensive mental health treatment in an environment that promotes participant empowerment and social engagement, VIP Boot Camp represents an integrative and innovative model of mental health treatment that offers benefits to veteran participants, HCPs, and the VHA.

Since 2007, Primary Care Mental Health Integration (PCMHI) at the Veterans Health Administration (VHA) has improved access to mental health care services for veterans by directly embedding mental health care professionals (HCPs) within primary care teams.¹ Veterans referred to PCMHI often have co-occurring physical and mental health disorders.² Untreated chronic physical and mental comorbidities can diminish the effectiveness of medical and mental health interventions. Growing evidence suggests that treatment of mental health conditions can improve physical health outcomes and management of physical conditions can improve mental health outcomes.^2,3

Chronic pain and sleep disorders are common reasons patients present to primary care, and often coexist together with mental health comorbidities.⁴ Sleep disorders affect 50% to 88% of patients with chronic pain, and 40% of patients with sleep disorders report chronic pain.⁴ Research has found that chronic pain and sleep disorders increase the risk of suicide attempts and deaths by suicide. Addressing suicide prevention simultaneously with treating chronic pain and insomnia is encouraged.⁵

Background

PCMHI treats physical and mental health comorbidities with a collaborative framework and a biopsychosocial integrative model.⁶ PCMHI staff provide mental health services as members of primary care teams. An interdisciplinary PCMHI team can include, but is not limited to, psychologists, mental health social workers, psychiatrists, nurse practitioners, clinical pharmacists, and mental health nurses. Quality of care within this model is elevated, as mental and physical health are recognized as interconnected. Collaboration between primary care and mental health benefits veterans and the VHA by increasing access to mental health care, decreasing stigma associated with mental health treatment, improving health outcomes, and enhancing the likelihood of recovery, resulting in high patient satisfaction.^6-8

In the existing PCMHI model, HCPs are encouraged to use short-term, evidence-based psychotherapies (EBPs).⁹ Veterans referred to PCMHI from primary care are typically able to attend 1 to 6 brief sessions of mental health treatment, often 20 to 30 minutes long. Most EBPs in PCMHI are disorder- specific, providing interventions focused on a single presenting problem (eg, insomnia, chronic pain, or posttraumatic stress disorder [PTSD]). For veterans with a single issue, this model can be very effective. ^1,10 However, the high rate of co-occurrence of mental and physical health issues can make it difficult to fully treat interrelated problems if the focus is on 1 specific diagnosis. Veterans with a need for additional (more comprehensive or intensive) mental health treatment are frequently referred to a higher, more resource-intensive level of mental health care, either in the VHA or the community. Examples of higher levels of mental health care include the longer term behavioral health interdisciplinary program (BHIP), sometimes called a mental health clinic (MHC), or a specialty mental health program such as a PTSD clinic.

As PCMHI continues to grow, new challenges have emerged related to staffing shortages and gaps in the clinical delivery of mental health treatment within the VHA. At the same time, demand for VHA mental health treatment has increased. However, a mental health professional shortage severely limits the ability of the VHA to meet this demand. In many systems, this shortage may result in more referrals being made to a higher level of mental health care because of fewer resources to provide comprehensive treatment in a less intensive PCMHI setting.^8,10,11 This referral pattern can overburden higher level care, often with long wait times for treatment and lengthy lag times between appointments. Furthermore, these gaps in the clinical delivery of care cannot be effectively addressed by hiring additional mental health professionals. This strain on resources can impede access to care and negatively affect outcomes.¹⁰

Recent congressional reports highlight these issues, noting that demand for mental health services continues to outpace the capacity of both PCMHI and higher levels of mental health care, leading to delays in treatment that may negatively affect outcomes.^8,10,11 These delays can be particularly detrimental for individuals with conditions requiring timely intervention.^8,11 Some veterans are willing to engage with PCMHI in a primary care setting but may be reluctant to engage in general mental health treatment. These veterans might not receive the mental health care they need without PCMHI.

Group Psychotherapy

A group psychotherapy format can address gaps in care delivery and provide advantages for patients, mental health professionals, and the VHA. Group psychotherapy aligns with the US Department of Veterans Affairs (VA) 2018 Blueprint for Excellence and 2018 to 2024 strategic plan, underscoring the need for more timely and efficient mental health services.^12,13

Benefits of group psychotherapy include reductions in symptoms, decreased feelings of isolation, increased social support, decreased emotional suppression, and enhanced satisfaction with overall quality of life.^14-17 Studies of veterans with PTSD have found less attrition among those who chose group therapy compared with individual therapy.^14,18 Group psychotherapy improves access to care by enabling delivery to more patients.¹⁴ When compared with individual therapy, the group format allows for a large number of patients to be treated simultaneously, maximizing resources and reducing costs.^3,19-21

VISN 9 CRH Innovation

The VA provides care to veterans through regionally distinct administrative systems known as Veterans Integrated Service Networks (VISNs). Clinical resource hubs (CRH) are VISN-based programs created to cover VA staffing shortages by virtually deploying HCPs into local VA systems until vacancies are filled. The national CRH vision of effectively using resources and innovative technologies to meet veterans’ health care needs, along with the above-referenced clinical gaps in the delivery of care, inspired the development of VIP Boot Camp within the VISN 9 CRH.²²

Program Description

VIP Boot Camp is an evidence-informed group psychotherapy program designed to provide timely, brief, and comprehensive mental health treatment for veterans. VIP Boot Camp was developed to address the needs of veterans accessing PCMHI services who experience ≥ 1 of the often overlapping problems of anxiety/emotion regulation/stress, sleep difficulties, and chronic pain (Figure). VIP Boot Camp uses an integrative approach to highlight interconnections and similarities among these difficulties and their treatment. A primary vision of the program is to provide this comprehensive treatment within PCMHI (upstream) so additional referrals to higher levels of mental health care (downstream) may not be needed.

This design is intentional because it increases the number of individuals who can be treated upstream with comprehensive, preventive, and proactive care within PCMHI which, over time, frees up resources in the BHIP for individuals requiring higher levels of care. This approach also aligns with the importance of early treatment for chronic pain and sleep disturbances, which are linked to increased risk of suicide attempts and deaths by suicide for veterans.⁵ National interest for VIP Boot Camp grew during fiscal year 2024 after it received the Gold Medal Recognition for Most Adoptable and Greatest Potential for Impact during VHA National Access Sprint Wave 3—Mental Health Call of Champions.

History

VIP Boot Camp began in August 2021 at VISN 9 as a 6-week virtual group for veterans with chronic pain. It was established to assist a large VA medical center experiencing PCMHI staffing shortages and lacking available PCMHI groups. Many veterans in the chronic pain group discussed co-occurring issues such as sleep disturbances, anxiety, and stress. The CRH team considered launching 2 separate groups to address these additional PCMHI-level issues; however, in developing the group material which drew from multiple clinical approaches, the team recognized significant overlapping and interconnected themes.

The team discussed EBPs within the VHA and how certain interventions within these treatments could be helpful across many other co-occurring disorders. Integrated tactics (clinical interventions) were drawn from cognitive-behavioral therapy (for depression, insomnia, or chronic pain), acceptance and commitment therapy, prolonged exposure, cognitive processing therapy, dialectical behavior therapy, unified protocol, pain reprocessing therapy, emotional awareness and expression therapy, interpersonal neurobiology, and mindfulness. We collaborated with veterans during VIP Boot Camp groups to determine how to present and discuss complex interventions in ways that were clinically accurate, understandable, relatable, and relevant to their experiences.

To address accessibility issues, the chronic pain group was reduced to 4 weeks. A second 4-week module for anxiety, emotion regulation, and stress was developed, mirroring the tactics, language, and integrative approach of the revised chronic pain module. A similar integrative approach led to the development of the third and final 4-week module for sleep disturbances.

Current Program

The VIP Boot Camp consists of three 4-week integrated modules, each highlighting a critical area: sleep disturbances (Improving Sleep), chronic pain difficulties (Outsmarting Chronic Pain), and emotion regulation difficulties (Rewiring Your Brain). VIP Boot Camp is designed for veterans who are at the PCMHI level of care. Referrals are accepted for patients receiving treatment from primary care or PCMHI.

Guidelines for participation in VIP Boot Camp may differ across sites or VISNs. For example, a veteran who has been referred to the BHIP for medication management only or to a specialty MHC such as a pain clinic or PTSD clinic might also be appropriate and eligible for VIP Boot Camp.

Given the interconnectedness of foundational themes, elements, and practices across the VIP Boot Camp modules, the modules are offered in a rolling format with a veteran-centric “choose your own adventure” approach. Tactics are presented in the modules in a way that allows patients to begin with any 1 of the 3 modules and receive treatment that will help in the other areas. Participants choose their core module and initial treatment focus based on their values, needs, and goals. Individuals who complete a core module can end their VIP Boot Camp experience or continue to the next 4-week module for up to 3 modules.

The group is open to new individuals at the start of any 4-week module and closed for the remainder of its 4-week duration. This innovative rolling modular approach combines elements of open- and closed-group format, allowing for the flexibility and accessibility of an open group with the stability and peer support of a closed group.

Given the complicated and overlapping nature of chronic pain, emotion regulation/ stress, and sleep disturbances, VIP Boot Camp acknowledges that everything is interconnected and difficulties in 1 area may impact other areas. The 3 interconnected modules with repeating themes provide coherence and consistency. Veterans learn how interconnections across difficulties can be leveraged so that tactics learned and practiced in 1 area can assist in other areas, changing the cycle of suffering into a cycle of growth.

VIP Boot Camp sessions are 90 minutes long, once weekly for 4 weeks, with 2 mental health professionals trained to lead a dynamic group psychotherapy experience that aims to be fun for participants. VIP Boot Camp synthesizes evidence-based and evidence-informed interventions, as well as techniques from VHA complementary and integrative health programs, psychoeducation, and interpersonal interventions that model connection, playfulness, and healthy boundaries. These varied strategies combine to equip veterans with practical tactics for self-management outside of sessions, a process described as “finding puzzle pieces.” VIP Boot Camp is built on the idea that people are more likely to adopt and practice any tactic after being taught why that tactic is important, and how it fits into their larger interconnected puzzle. After each session, participants are provided with additional asynchronous educational material to help reinforce their learnings and practices.

Although individuals may hesitate to participate in a group setting, they often find the experience of community enhances and accelerates their treatment and gains. This involvement is highlighted in a core aspect of a VIP Boot Camp session called wins, during which participants learn how others on their Boot Camp team are implementing new skills and moving toward their personal values and objectives in a stepwise manner. Through these shared experiences, veterans discover how tactics working for others may serve as a model for their own personal objectives and plans for practice. The sense of relief described by many upon realizing they are not alone in their experiences, along with the satisfaction felt in discovering their ability to support others in Boot Camp, is described by many participants as deeply meaningful and in line with their personal values.

While developed as a fully virtual group program, VIP Boot Camp can also be conducted in person. The virtual program has been successful and continues to spread across VISN 9. There are 8 virtual VIP Boot Camps running in VISN 9, with plans for continued expansion. In the VISN 9 CRH, Boot Camps typically have 10 to 12 participants. Additionally, as VIP Boot Camp grows within a location there are frequently sufficient referrals to support a second rolling group, which enables staggering of the module offerings to allow for even more timely treatment.

Training Program

VISN 9 CRH also developed a VIP Boot Camp 3-day intensive training program for PCMHI HCPs that consists of learning and practicing VIP Boot Camp material for chronic pain, emotion regulation/ stress, sleep disturbances, mindfulness, and guided imagery, along with gaining experience as a VIP Boot Camp coleader. Feedback received from PCMHI HCPs who completed training has been positive. There is also a private Microsoft Teams channel for HCPs, which allows for resource sharing and community building among coleaders. More than 75 PCMHI HCPs have completed VIP Boot Camp training and > 25 VIP Boot Camps have been established at 4 additional VISNs.

The VISN 9 CRH VIP Boot Camp program initiated an implementation and effectiveness project with the Michael E. DeBakey VA Medical Center and the South Central Mental Illness Research, Education and Clinical Center. The focus of this collaboration is support for implementation and treatment effectiveness research with reports, articles, and a white paper on findings and best practices, alongside continued dissemination of the VIP Boot Camp program and training.

Conclusions

VIP Boot Camp is a PCMHI group program offering readily available, comprehensive, and integrative group psychotherapy services to veterans experiencing . 1 of the following: chronic pain, emotion regulation/ stress, and sleep disturbances. It was launched at the VISN 9 CRH with a goal of addressing clinical gaps in the delivery of mental health care, by increasing the number of patients treated within PCMHI. The VIP Boot Camp model provides veterans the opportunity to transform cycles of suffering into cycles of growth through a single approach that can address multiple presenting and interconnected issues.

A 3-day VIP Boot Camp training program provides a quick and effective path for a PCMHI program to train HCPs to launch a VIP Boot Camp. The VISN 9 CRH will continue to champion VIP Boot Camp as a model for the successful provision of comprehensive and integrative mental health treatment within PCMHI at the VA. Through readily available access to comprehensive mental health treatment in an environment that promotes participant empowerment and social engagement, VIP Boot Camp represents an integrative and innovative model of mental health treatment that offers benefits to veteran participants, HCPs, and the VHA.

PHOENIX – Three decades after he initiated the transformation of the Veterans Health Administration (VHA) into a model research and clinical health care system, former US Department of Veterans Affairs (VA) Under Secretary of Health Kenneth W. Kizer, MD, MPH, urged cancer specialists to embrace this challenging moment as an opportunity for bold innovation.

At the annual meeting of the Association of VA Hematology/Oncology (AVAHO), Kizer acknowledged that the VA faces an “uncertain and turbulent time” in areas such as funding, staffing, community care implementation, and the rollout of a new electronic health record system. 

He also noted the grim rise of global instability, economic turmoil, climate change, infectious diseases, political violence, and mass shootings.

“This can be stressful. It can create negative energy. But this uncertainty can also be liberating, and it can prompt positive energy and innovation, depending on choices that we make,” said Kizer, who also has served as California’s top health official prior to leading the VHA from 1994 to 1999.

From “Bloated Bureaucracy’ to High-Quality Health Care System

Kizer has been credited with revitalizing VHA care through a greater commitment to quality, and harkened to his work with the VA as an example of how bold goals can lead to bold innovation. 

“What were the perceptions of VA health care in 1994? Well, they weren’t very good, frankly,” Kizer recalled. He described the VA as having a reputation at that time as “highly dysfunctional” with “a very bloated and entrenched bureaucracy.” As for quality of care, it “wasn’t viewed as very good.”

The system’s problems were so severe that patients would park motorhomes in VA medical center parking lots as they waited for care. “While they might have an appointment for one day, they may not be seen for 3 or 4 or 5 days. So they would stay in their motorhome until they finally got into their clinic appointment,” Kizer said.

Overall, “the public viewed the VA as this bleak backwater of incompetence and difference and inefficiency, and there were very strong calls to privatize the VA,” Kizer said. 

Kizer asked colleagues about what he should do after he was asked to take the under secretary job. “With one exception, they all said, don’t go near it. Don’t touch it. Walk away. That it’s impossible to change the organization.

“I looked at the VA and I saw an opportunity. When I told [members of the President Bill] Clinton [Administration] yes, my bold aim was that I would like to pursue this was to make VHA a model of excellent health care, an exemplary health care system. Most everyone else thought that I was totally delusional, but sometimes it’s good to be delusional.”

Revolutionary Changes Despite Opposition

Kizer sought reforms in 5 major strategic objectives, all without explicit congressional approval: creating an accountable management structure, decentralizing decision-making, integrating care, implementing universal primary care, and pursuing eligibility reform to create the current 8-tier VA system.

One major innovation was the implementation of community-based outpatient clinics (CBOCs): “Those were strongly opposed initially,” Kizer said. “Everyone, the veteran community in particular, had been led to believe that the only good care was in the hospital.”

The resistance was substantial. “There was a lot of opposition when we said we’re going to move out into the community where you live to make [care] easier to access,” Kizer said.

To make things more difficult, Congress wouldn’t fund the project: “For the first 3 years, every CBOC had to be funded by redirected savings from other things that we could do within the system,” he said. “All of this was through redirected savings and finding ways to save and reinvest.”

Innovation From the Ground Up

Kizer emphasized that many breakthrough innovations came from frontline staff rather than executive mandates. He cited the example of Barcode Medication Administration, which originated from a nurse in Topeka, Kan.

The nurse saw a barcode scanner put to work at a rental car company where it was used to check cars in and out. She wondered, “Why can’t we do this with medications when they’re given on the floor? We followed up on it, pursued those things, tested it out, it worked.”

The results were dramatic. “I was told at a meeting that they had achieved close to 80% reduction in medication errors,” Kizer said. After verifying the results personally, he “authorized $20 million, and we moved forward with it systemwide.”

This experience reinforced his belief in harvesting ideas from staff at all levels. 

Innovation remains part of the VA’s culture “despite what some people would have you believe,” Kizer said. Recently, the VA has made major advances in areas such as patient transportation and the climate crisis, he said. 

Inside the Recipe for Innovation

Boldness, persistence, adaptability, and tolerance for risk are necessary ingredients for high-risk goals, Kizer said. Ambition is also part of the picture. 

He highlighted examples such as the Apollo moon landing, the first sub-4-minute mile, and the first swim across the English Channel by a woman.

In medicine, Kizer pointed to a national patient safety campaign that saved an estimated 122,000 lives. He also mentioned recent progress in organ transplantation such as recommendations from the National Academies of Sciences, Engineering, and Medicine to establish national performance goals and the Organ Procurement and Transplantation Network’s target of 60,000 deceased donor transplants by 2026.

Bold doesn’t mean being reckless or careless, Kizer said. “But it does require innovation. And it does require that you try some new things, some of which aren’t going to work out.”

The key mindset, he explained, is to “embrace the unknown” because “you often really don’t know how you will accomplish the aim when you start. But you’ll figure it out as you go.”

Kizer highlighted 2 opposing strategies to handling challenging times. 

According to him, the “negative energy” approach focuses on frustrations, limitations, and asking “Why is this happening to me?” 

In contrast, a “positive energy” approach expects problems, focuses on available resources and capabilities, and asks, “What are the opportunities that these changes are creating for me?”

Kizer made it crystal clear which option he prefers.

Dr. Kizer disclosed that his comments represent his opinions only, and he noted his ongoing connections to the VA.

PHOENIX – Three decades after he initiated the transformation of the Veterans Health Administration (VHA) into a model research and clinical health care system, former US Department of Veterans Affairs (VA) Under Secretary of Health Kenneth W. Kizer, MD, MPH, urged cancer specialists to embrace this challenging moment as an opportunity for bold innovation.

At the annual meeting of the Association of VA Hematology/Oncology (AVAHO), Kizer acknowledged that the VA faces an “uncertain and turbulent time” in areas such as funding, staffing, community care implementation, and the rollout of a new electronic health record system. 

He also noted the grim rise of global instability, economic turmoil, climate change, infectious diseases, political violence, and mass shootings.

“This can be stressful. It can create negative energy. But this uncertainty can also be liberating, and it can prompt positive energy and innovation, depending on choices that we make,” said Kizer, who also has served as California’s top health official prior to leading the VHA from 1994 to 1999.

From “Bloated Bureaucracy’ to High-Quality Health Care System

Kizer has been credited with revitalizing VHA care through a greater commitment to quality, and harkened to his work with the VA as an example of how bold goals can lead to bold innovation. 

“What were the perceptions of VA health care in 1994? Well, they weren’t very good, frankly,” Kizer recalled. He described the VA as having a reputation at that time as “highly dysfunctional” with “a very bloated and entrenched bureaucracy.” As for quality of care, it “wasn’t viewed as very good.”

The system’s problems were so severe that patients would park motorhomes in VA medical center parking lots as they waited for care. “While they might have an appointment for one day, they may not be seen for 3 or 4 or 5 days. So they would stay in their motorhome until they finally got into their clinic appointment,” Kizer said.

Overall, “the public viewed the VA as this bleak backwater of incompetence and difference and inefficiency, and there were very strong calls to privatize the VA,” Kizer said. 

Kizer asked colleagues about what he should do after he was asked to take the under secretary job. “With one exception, they all said, don’t go near it. Don’t touch it. Walk away. That it’s impossible to change the organization.

“I looked at the VA and I saw an opportunity. When I told [members of the President Bill] Clinton [Administration] yes, my bold aim was that I would like to pursue this was to make VHA a model of excellent health care, an exemplary health care system. Most everyone else thought that I was totally delusional, but sometimes it’s good to be delusional.”

Revolutionary Changes Despite Opposition

Kizer sought reforms in 5 major strategic objectives, all without explicit congressional approval: creating an accountable management structure, decentralizing decision-making, integrating care, implementing universal primary care, and pursuing eligibility reform to create the current 8-tier VA system.

One major innovation was the implementation of community-based outpatient clinics (CBOCs): “Those were strongly opposed initially,” Kizer said. “Everyone, the veteran community in particular, had been led to believe that the only good care was in the hospital.”

The resistance was substantial. “There was a lot of opposition when we said we’re going to move out into the community where you live to make [care] easier to access,” Kizer said.

To make things more difficult, Congress wouldn’t fund the project: “For the first 3 years, every CBOC had to be funded by redirected savings from other things that we could do within the system,” he said. “All of this was through redirected savings and finding ways to save and reinvest.”

Innovation From the Ground Up

Kizer emphasized that many breakthrough innovations came from frontline staff rather than executive mandates. He cited the example of Barcode Medication Administration, which originated from a nurse in Topeka, Kan.

The nurse saw a barcode scanner put to work at a rental car company where it was used to check cars in and out. She wondered, “Why can’t we do this with medications when they’re given on the floor? We followed up on it, pursued those things, tested it out, it worked.”

The results were dramatic. “I was told at a meeting that they had achieved close to 80% reduction in medication errors,” Kizer said. After verifying the results personally, he “authorized $20 million, and we moved forward with it systemwide.”

This experience reinforced his belief in harvesting ideas from staff at all levels. 

Innovation remains part of the VA’s culture “despite what some people would have you believe,” Kizer said. Recently, the VA has made major advances in areas such as patient transportation and the climate crisis, he said. 

Inside the Recipe for Innovation

Boldness, persistence, adaptability, and tolerance for risk are necessary ingredients for high-risk goals, Kizer said. Ambition is also part of the picture. 

He highlighted examples such as the Apollo moon landing, the first sub-4-minute mile, and the first swim across the English Channel by a woman.

In medicine, Kizer pointed to a national patient safety campaign that saved an estimated 122,000 lives. He also mentioned recent progress in organ transplantation such as recommendations from the National Academies of Sciences, Engineering, and Medicine to establish national performance goals and the Organ Procurement and Transplantation Network’s target of 60,000 deceased donor transplants by 2026.

Bold doesn’t mean being reckless or careless, Kizer said. “But it does require innovation. And it does require that you try some new things, some of which aren’t going to work out.”

The key mindset, he explained, is to “embrace the unknown” because “you often really don’t know how you will accomplish the aim when you start. But you’ll figure it out as you go.”

Kizer highlighted 2 opposing strategies to handling challenging times. 

According to him, the “negative energy” approach focuses on frustrations, limitations, and asking “Why is this happening to me?” 

In contrast, a “positive energy” approach expects problems, focuses on available resources and capabilities, and asks, “What are the opportunities that these changes are creating for me?”

Kizer made it crystal clear which option he prefers.

Dr. Kizer disclosed that his comments represent his opinions only, and he noted his ongoing connections to the VA.

PHOENIX – Three decades after he initiated the transformation of the Veterans Health Administration (VHA) into a model research and clinical health care system, former US Department of Veterans Affairs (VA) Under Secretary of Health Kenneth W. Kizer, MD, MPH, urged cancer specialists to embrace this challenging moment as an opportunity for bold innovation.

At the annual meeting of the Association of VA Hematology/Oncology (AVAHO), Kizer acknowledged that the VA faces an “uncertain and turbulent time” in areas such as funding, staffing, community care implementation, and the rollout of a new electronic health record system. 

He also noted the grim rise of global instability, economic turmoil, climate change, infectious diseases, political violence, and mass shootings.

“This can be stressful. It can create negative energy. But this uncertainty can also be liberating, and it can prompt positive energy and innovation, depending on choices that we make,” said Kizer, who also has served as California’s top health official prior to leading the VHA from 1994 to 1999.

From “Bloated Bureaucracy’ to High-Quality Health Care System

Kizer has been credited with revitalizing VHA care through a greater commitment to quality, and harkened to his work with the VA as an example of how bold goals can lead to bold innovation. 

“What were the perceptions of VA health care in 1994? Well, they weren’t very good, frankly,” Kizer recalled. He described the VA as having a reputation at that time as “highly dysfunctional” with “a very bloated and entrenched bureaucracy.” As for quality of care, it “wasn’t viewed as very good.”

The system’s problems were so severe that patients would park motorhomes in VA medical center parking lots as they waited for care. “While they might have an appointment for one day, they may not be seen for 3 or 4 or 5 days. So they would stay in their motorhome until they finally got into their clinic appointment,” Kizer said.

Overall, “the public viewed the VA as this bleak backwater of incompetence and difference and inefficiency, and there were very strong calls to privatize the VA,” Kizer said. 

Kizer asked colleagues about what he should do after he was asked to take the under secretary job. “With one exception, they all said, don’t go near it. Don’t touch it. Walk away. That it’s impossible to change the organization.

“I looked at the VA and I saw an opportunity. When I told [members of the President Bill] Clinton [Administration] yes, my bold aim was that I would like to pursue this was to make VHA a model of excellent health care, an exemplary health care system. Most everyone else thought that I was totally delusional, but sometimes it’s good to be delusional.”

Revolutionary Changes Despite Opposition

Kizer sought reforms in 5 major strategic objectives, all without explicit congressional approval: creating an accountable management structure, decentralizing decision-making, integrating care, implementing universal primary care, and pursuing eligibility reform to create the current 8-tier VA system.

One major innovation was the implementation of community-based outpatient clinics (CBOCs): “Those were strongly opposed initially,” Kizer said. “Everyone, the veteran community in particular, had been led to believe that the only good care was in the hospital.”

The resistance was substantial. “There was a lot of opposition when we said we’re going to move out into the community where you live to make [care] easier to access,” Kizer said.

To make things more difficult, Congress wouldn’t fund the project: “For the first 3 years, every CBOC had to be funded by redirected savings from other things that we could do within the system,” he said. “All of this was through redirected savings and finding ways to save and reinvest.”

Innovation From the Ground Up

Kizer emphasized that many breakthrough innovations came from frontline staff rather than executive mandates. He cited the example of Barcode Medication Administration, which originated from a nurse in Topeka, Kan.

The nurse saw a barcode scanner put to work at a rental car company where it was used to check cars in and out. She wondered, “Why can’t we do this with medications when they’re given on the floor? We followed up on it, pursued those things, tested it out, it worked.”

The results were dramatic. “I was told at a meeting that they had achieved close to 80% reduction in medication errors,” Kizer said. After verifying the results personally, he “authorized $20 million, and we moved forward with it systemwide.”

This experience reinforced his belief in harvesting ideas from staff at all levels. 

Innovation remains part of the VA’s culture “despite what some people would have you believe,” Kizer said. Recently, the VA has made major advances in areas such as patient transportation and the climate crisis, he said. 

Inside the Recipe for Innovation

Boldness, persistence, adaptability, and tolerance for risk are necessary ingredients for high-risk goals, Kizer said. Ambition is also part of the picture. 

He highlighted examples such as the Apollo moon landing, the first sub-4-minute mile, and the first swim across the English Channel by a woman.

In medicine, Kizer pointed to a national patient safety campaign that saved an estimated 122,000 lives. He also mentioned recent progress in organ transplantation such as recommendations from the National Academies of Sciences, Engineering, and Medicine to establish national performance goals and the Organ Procurement and Transplantation Network’s target of 60,000 deceased donor transplants by 2026.

Bold doesn’t mean being reckless or careless, Kizer said. “But it does require innovation. And it does require that you try some new things, some of which aren’t going to work out.”

The key mindset, he explained, is to “embrace the unknown” because “you often really don’t know how you will accomplish the aim when you start. But you’ll figure it out as you go.”

Kizer highlighted 2 opposing strategies to handling challenging times. 

According to him, the “negative energy” approach focuses on frustrations, limitations, and asking “Why is this happening to me?” 

In contrast, a “positive energy” approach expects problems, focuses on available resources and capabilities, and asks, “What are the opportunities that these changes are creating for me?”

Kizer made it crystal clear which option he prefers.

Dr. Kizer disclosed that his comments represent his opinions only, and he noted his ongoing connections to the VA.

Background

Tall cell carcinoma with reversed polarity (TCCRP) is a rare and distinct subtype of invasive breast carcinoma, defined by tall columnar cells with eosinophilic cytoplasm and reversed nuclear polarity. TCCRP remains poorly characterized in the literature, with limited population-level evidence to guide management and prognostication. This study uses the National Cancer Database (NCDB) to examine the epidemiology, clinical features, and outcomes of this neoplasm.

Methods

A retrospective cohort analysis included 951 patients diagnosed with TCCRP (ICD-O-3 code 8509) from 2018–2020 using the NCDB. Demographic and treatment variables were analyzed using descriptive statistics. Incidence trends were assessed using linear regression, and overall survival was evaluated using Kaplan-Meier methods.

Results

Most patients were female (98.1%) with a mean age of 69.1 years. The majority were White (82.0%), followed by Black (9.0%) and Hispanic (8.7%). Primary tumor sites included overlapping breast lesions (28.5%) and the upper-inner quadrant (27.0%). Incidence remained stable (R² = 0.0). Most patients were diagnosed at Stage I (58.4%) and had a Charlson-Deyo score of 0 (76.2%). Socioeconomically, 41.8% lived in the highest income quartile (≥$74,063), and most had Medicare (64.7%). The most common treatment settings were comprehensive community cancer programs (40.3%). Surgery was performed in 95.6% of cases, with negative margins in 91.1%. Radiation therapy (46.6%) and hormone therapy (44.3%) were frequently used. Mortality was 1.1% at 30 days and 1.7% at 90 days. Survival was 98.9% at 2 years, 97.3% at 5 years, and 94.5% at 10 years, with a mean survival of 46.4 months.

Conclusions

This is the first NCDB-based study of TCCRP, highlighting favorable outcomes and distinct clinicodemographic features. Patients were predominantly older, White, and Medicare-insured, often receiving care at community cancer programs. These findings suggest that socioeconomic factors may influence access and treatment. Results may inform strategies to promote equitable care delivery across health systems and guide further research on clinical management and survivorship in TCCRP, particularly for rare cancers within community-based settings such as the VHA.

Background

Tall cell carcinoma with reversed polarity (TCCRP) is a rare and distinct subtype of invasive breast carcinoma, defined by tall columnar cells with eosinophilic cytoplasm and reversed nuclear polarity. TCCRP remains poorly characterized in the literature, with limited population-level evidence to guide management and prognostication. This study uses the National Cancer Database (NCDB) to examine the epidemiology, clinical features, and outcomes of this neoplasm.

Methods

A retrospective cohort analysis included 951 patients diagnosed with TCCRP (ICD-O-3 code 8509) from 2018–2020 using the NCDB. Demographic and treatment variables were analyzed using descriptive statistics. Incidence trends were assessed using linear regression, and overall survival was evaluated using Kaplan-Meier methods.

Results

Most patients were female (98.1%) with a mean age of 69.1 years. The majority were White (82.0%), followed by Black (9.0%) and Hispanic (8.7%). Primary tumor sites included overlapping breast lesions (28.5%) and the upper-inner quadrant (27.0%). Incidence remained stable (R² = 0.0). Most patients were diagnosed at Stage I (58.4%) and had a Charlson-Deyo score of 0 (76.2%). Socioeconomically, 41.8% lived in the highest income quartile (≥$74,063), and most had Medicare (64.7%). The most common treatment settings were comprehensive community cancer programs (40.3%). Surgery was performed in 95.6% of cases, with negative margins in 91.1%. Radiation therapy (46.6%) and hormone therapy (44.3%) were frequently used. Mortality was 1.1% at 30 days and 1.7% at 90 days. Survival was 98.9% at 2 years, 97.3% at 5 years, and 94.5% at 10 years, with a mean survival of 46.4 months.

Conclusions

This is the first NCDB-based study of TCCRP, highlighting favorable outcomes and distinct clinicodemographic features. Patients were predominantly older, White, and Medicare-insured, often receiving care at community cancer programs. These findings suggest that socioeconomic factors may influence access and treatment. Results may inform strategies to promote equitable care delivery across health systems and guide further research on clinical management and survivorship in TCCRP, particularly for rare cancers within community-based settings such as the VHA.

Background

Tall cell carcinoma with reversed polarity (TCCRP) is a rare and distinct subtype of invasive breast carcinoma, defined by tall columnar cells with eosinophilic cytoplasm and reversed nuclear polarity. TCCRP remains poorly characterized in the literature, with limited population-level evidence to guide management and prognostication. This study uses the National Cancer Database (NCDB) to examine the epidemiology, clinical features, and outcomes of this neoplasm.

Methods

A retrospective cohort analysis included 951 patients diagnosed with TCCRP (ICD-O-3 code 8509) from 2018–2020 using the NCDB. Demographic and treatment variables were analyzed using descriptive statistics. Incidence trends were assessed using linear regression, and overall survival was evaluated using Kaplan-Meier methods.

Results

Most patients were female (98.1%) with a mean age of 69.1 years. The majority were White (82.0%), followed by Black (9.0%) and Hispanic (8.7%). Primary tumor sites included overlapping breast lesions (28.5%) and the upper-inner quadrant (27.0%). Incidence remained stable (R² = 0.0). Most patients were diagnosed at Stage I (58.4%) and had a Charlson-Deyo score of 0 (76.2%). Socioeconomically, 41.8% lived in the highest income quartile (≥$74,063), and most had Medicare (64.7%). The most common treatment settings were comprehensive community cancer programs (40.3%). Surgery was performed in 95.6% of cases, with negative margins in 91.1%. Radiation therapy (46.6%) and hormone therapy (44.3%) were frequently used. Mortality was 1.1% at 30 days and 1.7% at 90 days. Survival was 98.9% at 2 years, 97.3% at 5 years, and 94.5% at 10 years, with a mean survival of 46.4 months.

Conclusions

This is the first NCDB-based study of TCCRP, highlighting favorable outcomes and distinct clinicodemographic features. Patients were predominantly older, White, and Medicare-insured, often receiving care at community cancer programs. These findings suggest that socioeconomic factors may influence access and treatment. Results may inform strategies to promote equitable care delivery across health systems and guide further research on clinical management and survivorship in TCCRP, particularly for rare cancers within community-based settings such as the VHA.