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VA clinic should fill big need's note: The following story was written by Kimberly Grodahl Albert, a graduate student at the University of Minnesota's health journalism and communication program. She wrote the story for one of her classes.

As veterans of Vietnam reach retirement age, and veterans of recent and ongoing conflicts make the transition back to civilian life, the demands on the Veterans Affairs (VA) system of medical care have increased.

That's true not only of direct medical spending - such spending increased statewide by 41 percent between 2002 and 2008, VA data show - but also of veterans' desire to receive treatment at facilities that are in close proximity to the places they live.

In some cases, those desires are being met by way of community based outpatient VA clinics, the newest of which will open later this year in Alexandria.

For veterans in west-central Minnesota in general, and Douglas County in particular, the new clinic likely will make receiving treatment for a variety of physical and mental conditions a more convenient affair.

And for the VA, the location just makes sense, according to Ray Kallstrom, Douglas County's veteran services officer.

"Alexandria was chosen because the veteran population in Douglas County has remained steady over the years, while other rural areas have decreased in veteran population," he said. "Alexandria also has specialty medical providers that the VA may need to utilize, as well as a very good hospital."

Statewide, the number of veterans fell between 1999 and 2008 by nearly 9 percent - from about 437,000 to 399,500.

Douglas County's veteran population, in contrast, increased by about 4 percent during that time - from 3,375 to 3,518 - and has been more than 3,500 in six of the last seven years.

The VA expects 3,500 veterans to enroll at the 9,915-square-foot clinic, which will serve veterans from Douglas, Grant, Pope, Stevens, Todd, and Wadena counties. (Veterans with VA benefits, however, can receive treatment at any facility they choose.) During the last 10 years, veteran populations in three of those counties, including Douglas, have grown - Pope by nearly 8 percent and Todd by 8 percent, but neither has as many veterans as does Douglas County.

There are fewer veterans in Grant, Stevens, and Wadena counties now than 10 years ago, according to VA data. But medical care spending in the six counties from which veterans are most likely to come has increased since 2002, though, in total, not as much as spending has increased statewide (from $391 million in 2002 to $661 million in 2008, or a 41-percent increase).

In Douglas County, for example, VA medical spending was about $4 million in 2002 and about $5.6 million in 2008. That's an increase of about 30 percent. During those years, the number of veterans who sought medical treatment rose from 1,116 in 2002 to 1,236 in 2008.

Data from recent years show that the number of Douglas County veterans who receive medical treatment has increased in recent years at a more rapid pace than has the total number of veterans, an indication that veterans are making use of VA health services at an increasing rate.

Medical care expenses in Todd County - where the second-highest number of veterans in the six-county area reside - increased by 59 percent between 2002 and 2008. During that time, the number of veterans who sought medical treatment more than doubled, too.

An outstate network

VA medical centers are located in Minneapolis, St. Cloud, and Fargo. Historically, if veterans wanted to apply for medical benefits and use them, they had to go to one of those three places. That worked fine for veterans who were in or near those areas, but left those who lived outside those areas dealing with both the time and monetary cost of having to travel to receive care.

During the 1990s, though, the VA changed its health services delivery system and moved from an inpatient to an outpatient model, which allows it to open community based clinics in various parts of the state.

"It's now an efficient, well integrated system that relies on VA medical centers in Minneapolis, St. Cloud, and Fargo only for more intensive services," said Milt Schoen, Hennepin County's veteran services officer.

In Hennepin County, the veteran population has fallen by 28 percent - from more than 100,000 to about 72,500 - since 1999. Part of the reason could be that as veterans reach retirement age, they move to rural places like Douglas County.

Indeed, rural areas have a higher proportion of elderly veterans, Schoen said.

But he figures about 75 percent of the mental health professionals are in the metro area.

"A challenge the VA is facing nationwide is how to get mental health care in rural areas," Schoen said.

A focus on mental health

Community based outpatient clinics could be a start.

Medical care remains the primary reason for which veterans receive treatment - and many of them don't apply for the benefits that entitle them to medical treatment, believing as they do that other veterans are in worse shape than them. But the number of veterans seeking help for their mental health is rising, even as there still is a relative lack of awareness about mental health issues, Schoen said.

The VA medical system is uniquely capable of dealing with mental health issues, specifically those related to their experiences in war, he said. Still, mental health problems often aren't recognized right away, but instead become apparent when veterans struggle with the issues of daily life over time.

And while a higher percentage of veterans of the current wars experience combat or other dangerous situations, some Vietnam veterans now are seeking treatment, perhaps because the Iraq war news brings back memories of the conflict in which they served.

Whatever the reason for treatment, mental health services are a vital part of the VA medical system, Kallstrom said.

"The Department of Veterans Affairs has realized over the past years that this has to be part of the care provided at community based outpatient clinics," Kallstrom said. "The need for mental health services in the community is vital to the overall care a veteran receives.

"Depending on the individual, there may be more appointments in mental health [at the new outpatient clinic in Alexandria], which will save travel time to the St. Cloud VA Medical Center. Often, these clients do not drive or do not have the financial means to make these trips."

Schoen expects the need for mental health services to continue to rise.

"You just can't take a snapshot right now and say we know what the true costs of this war are," he said. "In the future, we'll be able to find correlations between cause and effect."

Post-traumatic stress disorder (PTSD) is one of the mental health problems that health professionals are paying particular attention to. Schoen estimates that, conservatively, 17 percent to 20 percent of veterans experience PTSD or other behavioral issues as they assimilate back into civilian life.

PTSD has been around for a long time, and has been known by different names over the years. The condition has been referred to as PTSD since the late 1980s, Kallstrom said.

The number of PTSD cases and claims related to current conflicts has been less than what experts predicted would be seen, he said.

"There has been a greater effort to reach out to our current returning veterans and to see them in the mental health clinic, if appropriate, to counsel these veterans to prevent their conditions from developing into PTSD," Kallstrom said.