VetSET Nebraska is a collaboration between the members of Nebraska’s SACCHO, the Nebraska Association of Local Health Directors (NALHD). The jurisdictions of NALHD’s 21 members cover all 93 of Nebraska’s counties and the Winnebago Tribal Health Department. Each local health department (LHD) in Nebraska is locally-governed with distinct management, structure, and programs. Each serves a jurisdiction of from 1 to 11 counties that are collectively home to the entire state population (1,934,408). Approximately 124,500 United States Military Veterans plus their families live in these jurisdictions. 

Since 2015, NALHD has been implementing the unique, statewide VetSET program that applies public health approaches—and leverages the unique position and expertise of LHDs as Chief Health Strategists—to support connection, resiliency, and wellbeing of Veterans and their families.  VetSET broadly defines a Veteran as one who served or is currently serving in the United States Military.  

The public health needs of Veterans and their families are frequently overlooked and unknown, in part because public health demographic data typically does not identify these populations. National data suggests that, when compared to the general population, Veterans and their families disproportionately suffer from negative risk factors and health outcomes that impact overall community wellbeing—including suicide and behavioral health issues.   

These health issues, when addressed, are often being addressed in local communities.  Many Veterans and most of their family members are not eligible for VA services and those who are often choose to use services close to home. Therefore, Veterans and their families make up a significant proportion of the target population across all programs in every LHD in Nebraska—and across the country.  2016 Nebraska BRFSS data suggest that over 50% of adult Nebraskans are Veterans or Veteran-connected family members. Additionally, 23% of school aged children report their parent or guardian is connected to the military. These data are not readily available nationally. 

Veteran-connected family members—who are often the first responders when Veterans and Service Members are in crisis—deserve and need the attention of local public health systems. Nebraska’s recent BRFSS data show that spouses and partners of Veterans have significantly more poor mental health days and are more likely to have been told that they have depression than the population as a whole. Also, Nebraska students with a military connection (through their parent or guardian) are significantly more likely to report that they considered attempting suicide, attempted suicide, and engaged in self-harm. They are also more likely to use alcohol, tobacco, and prescription drugs. (see: Students_from_Military_Families_07_06_2020.pdf (unmc.edu)) 

To address these concerning statistics, Veterans and their families need to be surrounded by whole communities of cross-sector organizations that are broadly aware of and working to address their challenges. VetSET Nebraska works toward this with these overarching goals: 

1.      Build capacity within and collaboration between military-serving and civilian-serving partners in LHD jurisdictions and statewide. 

2.      Support a range of LHD-specific activities that engage and serve Veterans and families in their local communities. 

3.      Build LHDs’ suicide prevention ability, especially to reach Veterans and their families.  

4.      Develop sustainable mechanisms for collecting, synthesizing, and sharing surveillance data on Veteran and families’ health and wellbeing. These data provide direction for local policies and programs. 

Through VetSET, LHDs have made military cultural competence part of the foundational skillset of the public health workforce in Nebraska. Statewide, LHD staff participate in various Military 101 Training and other awareness-raising training events (see 2017 Model Practice, VetSET Nebraska).  Staff at the LHDs apply this knowledge in developing new community partnerships, with the purpose of serving Veterans and families. Partner organizations also participate in VetSET trainings, thereby improving military cultural competence across the public health system—among military-serving and civilian-serving providers. These partnerships are supported at the SACCHO level by the VetSET Program Director and her facilitation of a state-level Task Force. 

VetSET work makes Veterans and their families more visible across the public health system. Initially, VetSET LHDs encouraged community partners to ask their employees, students, and clients if ‘they or a family member ever served in the military’. This grass roots initiative cascaded into formalizing additional questions (Military Connection Screener) on Nebraska's 2016 (and later the 2018) BRFSS (Behavioral Risk Factor Surveillance System). A similar screener was permanently added to the Nebraska Risk and Protective Factor Student Survey (NRPFSS) in 2018.  These demographic questions, for the first time, allow LHDs to understand and monitor how Veteran-connected family members disproportionately experience a range of mental health issues when compared to other groups. These findings help to guide community organizations to better serve their Veteran-connected clients/patients/students. 

Funding partners recognize the opportunity in the unique LHD-driven approach to serving this population. Since 2015, VetSET Nebraska has engaged and has been supported by local, state, and federal entities in the public health and Veteran spaces (including: the Veterans Administration [VA] Office of Rural Health, the Prevention Institute/Movember Foundation’s Making Connections program, the Behavioral Health Education Center of Nebraska [BHECN], Center for Disease Control [CDC] Foundation, The Nebraska Departments of Health and Human Services and of Veterans Affairs, local community foundations, and others). 

Nebraska’s Veterans and their families (a previously underserved and somewhat invisible subpopulation) today are more likely encounter a local public health system that better-understands the opportunities and challenges of military life. VetSET is an important aspect of Nebraska LHDs’ broader efforts as Chief Health Strategists. 

https://nalhd.org/our-work/vetset/ 

The public health needs of Veterans and their families are frequently overlooked and unknown, in part because public health demographic data typically does not track these populations. Many Veterans and their family members are not eligible for VA services and those who are, often choose to use services in their home communities. As a result, in every LHD in the country, across almost all programs, Veterans and their families make up a significant proportion of the target population. Available evidence increasingly suggests that these groups disproportionately suffer from some negative risk factors and health outcomes when compared to the general population. 

To better understand the needs of Nebraska Veterans and their families, NALHD and member LHDs worked with the Division of Public Health in the Nebraska Department of Health and Human Services and the Nebraska Department of Education to add Veteran-connection questions to the Behavioral Risk Factor Surveillance System (BRFSS) and the Nebraska Risk and Protective Factor Student Survey (NRPFSS). In 2016, a question was added to the BRFSS survey. To our knowledge no similar screener has been implanted in any other state, though the resulting data could be beneficial nationally. Respondents were asked if they had ever served in the U.S. military or if they had a parent/guardian, sibling, spouse or significant other, or child serve in the U.S. military. The results indicated that while only 11% of Nebraskans ever served in the military, over 60% of Nebraska’s adults are Veteran-connected (a parent/guardian, sibling, spouse/partner, or child of someone who served). Spouses or significant others appeared to be more affected by mental health issues. More specifically, in the spouse/significant other group, 17.0% reported that their mental health was not good on 14 or more of the past 30 days as compared to 9.6% for the total population, a statistically significant difference. In addition, spouses and significant others reported being told that they have depression by a health professional at significantly higher rates than the general population (29.7% vs 17.9%).  This screener was adminstered again in 2018. Data are currently under analysis.

In the 2018 NRPFSS, a question was added to allow comparisons between students with parents or guardians who had ever served in the military and those whose parents or guardians had not. Students from the 8th, 10th, and 12th grades across Nebraska responded to several questions related to mental health status, substance use and misuse, nutrition and exercise habits, and risk and protective factors. The resulting data revealed statistically significant differences when students from military families were compared with students from non-military families. For example, students from military families were more likely to have considered suicide (21% vs 15%), had a higher rate of lifetime alcohol use (45% vs 43%), and had a higher rate of lifetime tobacco use (20% vs 16%). 

These findings call on LHDs nationwide to identify and engage with Veterans and their families in local communities to maximize the effectiveness of behavioral health and substance abuse interventions in particular. VetSET is a roadmap for accomplishing this that includes: 

1.      At local and state levels, monitor the health status of Veteran-connected community members, not just Veterans—in some cases by simply adding a Veteran-connection screener to intake forms; in other cases by engaging with state BRFSS coordinators and other officials to change demographic questions. 

2.      Engage LHD staff and partners across the (civilian) public health system in education and capacity building that broadly increases military cultural competence. 

3.      Network with Veteran and civilian serving organizations to increase capacity to provide interventions and programs that are inclusive of Veterans and their families. 

2018 NRPFSS Report:  https://nalhd.org/file_download/4bb66a86-e316-4b27-88aa-7199de4234f6 

2016 BRFSS Analysis report:  https://nalhd.org/file_download/976bf462-fc5f-4dc8-8517-86ff845982cb 

NALHD’s VetSET Nebraska program has been leading statewide efforts to prepare communities to be ‘set’ (ready) to harness their strengths to support connection, resiliency, and wellbeing of Veterans and their families.  Leading the program ats the SACCHO-level aligns with many Veteran services which are driven from the state and federal level.  NALHD is positioned to collaborate with state-wide and national partners and provide content expertise, thereby enabling the member LHDs to partner and lead locally for the betterment and focus of their individual communities.  

In 2013 and 2014, LHDs noted the relative absence of military and Veteran engagement in their Community Health Improvement Plans (CHIPs) process and were worried about the implications. The resulting VetSET program has since evolved to the current goals and objectives: 

1.      Build capacity within and collaboration between military-serving and civilian-serving partners in LHD jurisdictions and statewide. 

a.      Provide backbone support to the Nebraska Veteran and Family Task Force (NVFTF).  NVFTF is a unique cross-sector, grassroots forum for a range of partners to learn together, coordinate efforts, and collaborate for strategic impact. 

b.      Provide outreach and tailored training and technical assistance to civilian partners across each VetSET LHD jurisdiction. 

c.      Support all LHD staff onboarding and ongoing skill building. 

2.      Support a range of local, LHD-specific activities that engage and serve Veterans and families in their local communities. 

3.      Build LHDs’ suicide prevention ability, especially to reach Veterans and their families.  

a.      Provide Veteran-focused QPR (Question. Persuade. Refer.) Gatekeeper Suicide Awareness workshops in communities across the state and on a virtual platform. 

4.      Develop sustainable mechanisms for collecting, synthesizing, and sharing surveillance data on Veteran and families’ health and wellbeing. These data provide direction for local policies and programs. 

a.      Institutionalize Veteran-connection screeners in all state-level surveillance surveys—including the BRFSS and the NRPFSS. 

NALHD and LHDs assumed the role of convener and informer with stakeholders.  A key feature of NALHD’s VetSET program is the involvement with the Nebraska Veteran and Family Task Force (NVFTF), a statewide, cross-sector collective impact group working to highlight issues and advance solutions in the Veteran and Veteran family space. NALHD provides backbone support to the NVFTF, starting in 2017 when it facilitated a day-long strategic reset of the floundering group. Today a rejuvenated Task Force meets bi-monthly, convening over 60 different individuals representing civilian and military sectors.  While the task force engages many state and federal-level partners, individual LHDs and local partners also actively participate, bringing the rural voice to discussion and decision making. Mirroring aspects of the Chief Health Strategist role at the state level, the SACCHO is a logical and appropriate facilitator of this group. 

LHD Executive Directors demonstrate leadership commitment for their Veteran work by prioritizing VetSET and military cultural competence as a training block during their staff onboarding processes.   

VetSET LHDs engage with their community partners in ways that increase partners’ knowledge and awareness about Veteran-specific issues and concerns.  They rely on their own skills and capacity as well as the support housed at the SACCHO-level.   Engagement activities are often driven by local CHIPs and range from engineering social gatherings for Veterans and Veteran families that promote emotional connection and healthy activities; to identifying gaps in service for Veterans and their families; to collaborating with community partners on strategies to meet these needs. The LHDs engage with local service providers focused on the military and Veterans as well as community partners such as schools, law enforcement, employers, community organizations and many others. This cross-sector, community-wide approach helps to broaden the base of people in local communities who are working towards the same goal of awareness and service to Veterans and their families. 

VetSET has improved the military cultural competence LHD staff and their partners in health care, education, law enforcement, community development, faith-based organizations, local and state government. To date, over 1,000 individuals have participated in No Wrong Door trainings across Nebraska. VetSET’s No Wrong Door builds military cultural competence while also incorporating targeted networking between participants. These events have been the genesis of relationships—including local work groups and task forces—that advocate for Veterans and their families. No Wrong Door is relevant to a broader range of participants: health professionals, counselors, community members, clergy, law enforcement, employers–anyone who needs to be ready for Veterans and their families when they walk through the door. Evaluation of this Continuing Education Unit (CEU)-awarding curriculum shows that it significantly enhances participants’ awareness and understanding of the particular needs of service members, Veterans and their families as they face the challenges on the home front.  No Wrong Door introduces community providers to the “invisible” wounds of war, services, and resources so all can support Veterans and their families in local communities. No Wrong Door provided a way for LHDs, their staff, and their key partners to build shared expertise on Veteran’s issues in Nebraska that they can apply to their work, including with VetSET. No Wrong Door and the shorter Military 101 have remained a key piece of the VetSET program and serve as a mechanism for engaging partners across the state. 

VetSET has developed suicide prevention skills to over 700 rural and suburban community members through Veteran-focused workshops that include QPR (Question. Persuade. Refer.) Gatekeeper training. Veteran-focused QPR Gatekeeper suicide prevention training, customized by NALHD, raises local awareness and contributes to Veteran-focused tactics in several CHIPs. 

Even amidst a pandemic, NALHD and LHDs collaborated through monthly check-ins, mini-training opportunities, virtual meetings, and the use of virtual collaboration platforms which aided greatly in maintaining relevance and a consistent focus on Veterans and their families.   

To develop sustainable mechanisms for collecting, synthesizing, and sharing surveillance data on Veteran and families’ health and wellbeing, NALHD led and continues to lead efforts to add military connection screeners to the Nebraska Behavioral Risk Factor Surveillance System (BRFSS) survey and to the Nebraska Risk and Protective Factors Student Survey (NRPFSS). These screeners are providing ongoing insight into the health and wellbeing of military-connected families in Nebraska. Their data show that Veteran spouses and partners have more poor mental health days and are more likely to have been told that they have depression than the population as a whole. Also, Nebraska students with a military connection (through their parent or guardian) are significantly more likely to report that they considered attempting suicide, attempted suicide, and engaged in self-harm. They are also more likely to use alcohol, tobacco, and prescription drugs. NALHD is partnering with the University of Nebraska Medical Center’s College of Public Health to develop the second brief based on these unique data sources. The first of the briefs is at Students_from_Military_Families_07_06_2020.pdf (unmc.edu).  NALHD’s VetSET team is also working on messages, side decks, and social media assets that feature these data findings and are designed to influence policy to support Veterans and families. 

Time and resources demanded to implement a program like VetSET are significant and require dedicated funding for a Veteran-focused coordinator/manager. Ideally this type of program is led by someone with military experience and ties to the Veteran community. Without at least one position of statewide leadership to mentor, support, influence and inform LHDs and partners, the work would fall short. 

Additional key expenses include travel and facilities costs for local training and funding for data collection. The actual cost to have the 2018 the Veteran Connection Screener added to the BRFSS was $11,000 – plus evaluation and analysis ($10,000).  Other costs to support member LHD's specific activity varied widely depending on funding available. NALHD was able to attract larger grants based on statewide reach, sizable proportions of which went to member LHDs to support specific work. 

Since 2015, NALHD has employed a variety of tools to monitor and evaluate VetSET implementation and impact. These included several tools required by various funding partners (VA Office of Rural Health, Movember Foundation/Prevention Institute, CDC Foundation, Behavioral Health Education Center of Nebraska) as a requirement of their funding.  

Using tools provided by the VA Office of Rural Health and an end-of-funding-cycle survey from 2014-2017 NALHD found that:  

o   Veterans were often invisible in their communities and uncertain of where to turn for Veteran specific support and resources.  LHDs screened (2,210) and referred for services (501) Veterans and/or families filling the gap in rural communities. 

o   Conducting outreach events to make contact with Veterans and their families was a major component of LHDs' VetSET strategy.  A total of 411 outreach events were conducted, including county fairs, agency staff meetings, faith events, worksite wellness events, and numerous Veteran events, and many other diverse activities. 

o   Collectively, 15 LHDs created a total of 878 new partnerships in the areas they represent and a variety of area agencies, with the focus of serving Veterans and improving military cultural competency. Of the 878 total new partnerships, 856 partners were located across 63 Nebraska Counties. An additional 22 partnerships made with organizations located outside of the state, mostly led at the SACHHO-level.

o   All VetSET LHDs had incorporated Veteran Connection questions as part of their Client Intake Questionnaire at the end of this inital work.   This tool is a brief needs assessment for initial intake of Veterans or family members.  NALHD’s VetSET team continues to push for broad implementation of Veteran Connection questions in these contexts. 

To ensure that the VetSET evaluation could adequately address the areas of emphasis most important to LHDs as Chief Health Strategists, in 2015 NALHD independently implemented several evaluation tools with the input of an outside evaluation team. These included... 

o   Comprehensive No Wrong Door Evaluation: No Wrong Door participants represented LHDs (20%), Community Organizations (12%), Health Care (14%), Government (12%), VA (6%) and other partners. Participants’ familiarity and comfort with aspects of military and Veteran culture, increased significantly and those improvements persisted over time as indicated by pre, post and 6-month follow-up surveys. Immediately following the trainings, just under 75% of participants agreed or strongly agreed that their overall impression of Veterans has changed as a result of attending the training. Over 90% agreed or strongly agreed that they are more aware of the challenges facing Veterans and their families as a result of the training. Over 78% agreed, post-training that they now know effective communication skills to use when working with Veterans – up from 35% pre-training. 

o   All No Wrong Door training attendees were twice invited to participate in a brief survey of military cultural competency. This tool was based upon the tool that was used in the 2014 Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families study by the RAND Corp. The purpose of NALHD’s version of this tool was to ascertain the impact the No Wrong Door training had on participants’ understanding of military and Veteran culture and their level of comfort in serving Veterans. A total of 290 individuals responded to the pre-survey (response rate: 57.1%). The response rate dropped considerably for the follow-up, but was still a respectable 36.6%, with 186 responses collected. The pre- and follow-up surveys were administered via SurveyMonkey, to all participants (the week prior to the given No Wrong Door and again 6 months after the workshop). All data were analyzed with SPSS version 22. Frequencies and cross-tabs were performed. All of these survey items showed a statistically significant improvement from pre- to follow-up (p<.05). Participants’ perceived knowledge of military culture and perceived knowledge and ability to communicate with Veteran clients improved. Participants perceived ability to provide needs-based services for Veterans and their families improved. 

University of South Florida (USF) devised a Mental Well-Being Inventory for partners in the Movember Foundation/ Prevention Institute work. This tool sought to measure mental well-being change over time.  Qualitative and quantitative data from 31 different counties suggest that VetSET program has had a positive impact on Veterans in rural Nebraska and that the majority of Veterans felt valued in their community.  

USF also collected a Social Network Analysis. The purpose of this survey was to better understand how each LHD worked together and with NALHD in the VetSET work.  Findings suggest that commitment and reliability among coalitions members were high. However, Shared Risks in terms of contributions of time, money, and other resources presented as an area in need of improvement across VetSET LHDs. There was also evidence, that a single agency/partner (NALHD) was most responsible for communication, decision-making, and contributing resources towards the work.  NALHD applied these data as part of strategic planning around VetSET sustainability in 2019. 

NALHD and several LHDs offer QPR Gatekeep Suicide Prevention training.  In just over two years, over 700 different Nebraskans have received this Veteran-focused training.  Each participant completes both a Pre and Post survey, measuring level of knowledge and applicability. These data indicate that the trainings are overwhelmingly well-received and useful.  This training is made possible through a grant with University of Nebraska Medical Center (UNMC) Behavioral Health Education Center of Nebraska (BHECN).   Data from this project is reported to SAMSHA. 

In the 2020 NALHD membership survey, LHDs indicated that the relationships and the expertise built through their participation in the VetSET program contributed to their readiness during the current pandemic. (2.75 and 2.63 on a 5-point scale).   Several LHDs developed community partner relationships with organizations through the VetSET work that were previously not established.  For example, response to the pandemic, military and LHDs joined forces in testing and deployment strategies. Military cultural competence as well as previous relationships with military leadership resulted in smoother operations. 

In 2021, NALHD will benefit from the evaluation expertise from the CDC Foundation to craft a strategy to evaluate how well NALHD’s VetSET program is engaging the NFVTF partners as key amplifiers of usable data assets, especially in the new, virtual environment.   Available data is compelling. Paramount is identifying to what extent are the VetSET data sharing efforts leading to an increase in usable data for key decision-makers. NALHD developed a sustainable plan for evaluating the usability of the assets developed from the data. This is, and will continue to be, an ongoing quality improvement process that helps inform the state’s upstream suicide prevention efforts that target Veterans and their families. 

Program, practice, and policy has been the path NALHD has set for VetSET, creating a unique way forward for each LHD that has taken on this project locally. NALHD staff expertise supports the teams at member LHDs to keep those LHDs “set to serve Vets” over the long-term. NALHD’s VetSET Project Director develops and maintains policy and procedure resources around orienting new LHD staff and refreshing and updating training for existing LHD staff around Veterans’ and families’ needs.  She also provides an expert sounding board for LHDs and their partners. 

VetSET has increased sustainable, statewide capacity to serve Veterans and their families across sectors by... 

Coordinating the Nebraska Veteran and Families Task Force (NVFTF) – a state-level forum for cross-sector partnership and collaboration for strategic impact. NVFTF is the Nebraska/Western Iowa Veteran Administrations’ (VA) Community Veteran Engagement Board (CVEB). 

Improving the military cultural competence of over 1,000 LHD staff and partners in health care, education, law enforcement, community development, faith-based organizations, local and state government by way of No Wrong Door trainings across Nebraska. VetSET’s No Wrong Door builds military cultural competence while also incorporating targeted networking between participants. These events have been the genesis of relationships—including local work groups and task forces—that advocate for Veterans and their families. 

Promoting local policies whereby employers, schools, and other entities identify the Veteran-connected individuals they employ and serve.   

Building the suicide prevention skills of over 700 rural and suburban community members through Veteran-focused workshops that include QPR (Question. Persuade. Refer.) Gatekeeper training. Military-focused QPR Gatekeeper suicide prevention training raises local awareness and contributes to Veteran-focused tactics in several Community Health Improvement Plans—the cornerstone of local public health strategy. 

Formalizing military cultural competence and awareness training as part of LHD staff onboarding and professional development. This ensures ongoing, statewide capacity for our public health system to work effectively in the Veteran space. Of note: in 2019, LHDs identified the skills and connections built under VetSET as beneficial to their response to the COVID-19 pandemic. 

Initiating systems to better monitor the health status of Veterans and their families. NALHD led efforts to add military connection screeners to the Nebraska Behavioral Risk Factor Surveillance System (BRFSS) survey and to the Nebraska Risk and Protective Factors Student Survey (NRPFSS). These screeners provide ongoing insight into the health and wellbeing of military-connected families in Nebraska