given to the resources and the organization—the system of care—that are marshaled for the management of CMI patients.

This chapter presents a patient-centered management approach for veterans who have CMI. It begins by describing some of the current capabilities of the Department of Veterans Affairs (VA) for managing the health of veterans. It identifies inadequacies of existing VA models of care for veterans who have CMI and recommends a general approach to the management of such veterans. The chapter next describes models of care used by other organizations to manage CMI patients. Building on information presented in Chapter 6, it ends with a discussion of how information about managing CMI might be disseminated to VA clinicians and patients.


Veterans use the full array of health care benefits and systems for their care: the Veterans Health Administration (VHA); TRICARE, the Department of Defense (DOD) health care program for active-duty, reserve, and retired armed forces personnel; Medicare; and private care. Fewer than 20% of all veterans receive their health care exclusively in VHA facilities, about one-third of veterans use Medicare benefits, and almost half use both (Hynes et al., 2007; Petersen et al., 2010; Stroupe et al., 2005; West et al., 2008). The distribution among the health care system of veterans who have CMI is not known, nor is there any difference in the pathway of care between veterans of the 1991 Gulf War and veterans of the Iraq and Afghanistan wars (Operation Iraqi Freedom, Operation New Dawn, and Operation Enduring Freedom).

More than 8 million veterans are enrolled in VHA (Walters, 2011). In FY 2009, the number of pre–September 2001 Gulf War–era veterans receiving health care through VHA was 571,656 (VA, 2011d).1 That number represents 8.7% of the total Gulf War–era veteran cohort. Of the pre–September 2001 Gulf War–era veterans receiving care from VHA, 145,832 were deployed to the Persian Gulf and 110,487 of the deployed personnel were active participants in the Gulf War. Inpatient care in VHA facilities was used by 24,578 pre–September 2001 Gulf War–era veterans in FY 2009, and outpatient care was used by 540,802 Gulf War–era veterans in the same year. About 55% of veterans of the Iraq and Afghanistan wars (834,463 veterans) have used VHA health care services since October 2001


1For this case, Gulf War–era veterans are defined as military personnel who served on active duty during August 2, 1990–September 10, 2001. Not all Gulf War–era veterans were deployed to the Persian Gulf or were Gulf War participants.

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