Program Profile

Military medical personnel rely on individual critical tasks lists (ICTLs) to maintain proficiency in essential medical skills during deployments. However, sustaining these competencies in a low-casualty operational setting presents unique challenges. Traditional training methods, such as lectures or simulations outside operational contexts, may lack engagement and fail to replicate the stressors of real-world scenarios. Previous research has emphasized the importance of continuous medical readiness training in austere environments, highlighting the need for innovative approaches.^1,2

The Litter Olympics was developed as an in-theater training exercise designed to enhance medical readiness, foster interdisciplinary teamwork, and incorporate physical exertion into skill maintenance. By requiring teams to carry a patient litter through multiple “events,” the exercise reinforced teamwork within a medical readiness-focused series inspired by an Olympic decathlon. This article discusses the feasibility, effectiveness, and potential impact of the Litter Olympics as a training tool for maintaining ICTLs in a deployed environment.

Program

The Litter Olympics were implemented at a Role 3 medical facility in Baghdad, Iraq, where teams composed of individuals from military occupational specialties (MOSs) and areas of concentration (AOCs) participated. Role 3 facilities provide specialty surgical and critical care capabilities, enabling a robust medical training environment.³ The event was designed to reflect the interdisciplinary nature of deployed medical teams and incorporated hands-on training stations covering critical medical skills such as traction splinting, spinal precautions, patient movement, hemorrhage control, airway management, and tactical evacuation procedures.

Tasks were selected based on their relevance to deployed medical care and their inclusion in ICTLs, ensuring alignment with mission-essential skills. Participants were evaluated on task completion, efficiency, and teamwork by experienced medical personnel. Postexercise surveys assessed skill improvement, confidence levels, and areas for refinement. Future studies should incorporate structured performance metrics, such as pre- and postevent evaluations, to quantify proficiency gains (Table 1).

Five mixed MOS/AOC teams participated in the event, completing the exercise in an average time of 50 minutes (Table 2). Participants reported increased confidence in performing ICTs, particularly in patient movement, hemorrhage control, and airway management. The interdisciplinary nature of the teams facilitated peer teaching and cross-training, allowing individuals to better understand each other’s roles and responsibilities. This mirrors findings in previous studies on predeployment training that emphasize the importance of collaborative, hands-on learning.⁴ The physical aspect of the exercise was well received, as it simulated operational conditions and reinforced endurance in high-stress environments. Some tasks, such as cricothyroidotomy and satellite radio setup, required additional instruction, highlighting areas for improvement in future iterations.

Discussion

The Litter Olympics provide a dynamic alternative to traditional classroom instruction by integrating realistic, scenario-based training. However, several limitations were identified. The most significant was the lack of formalized outcome metrics. While qualitative feedback was overwhelmingly positive, no structured performance assessment tool, such as pre- and postevent skill evaluations, was used. Future studies should incorporate objective measures of competency to strengthen the evidence base for this training model. Additionally, participant feedback suggested that more structured debriefing sessions postexercise would enhance learning retention and provide actionable insights for future program modifications.

Another consideration is the scalability and adaptability of the exercise. While effective in a Role 3 setting, modifications may be required for smaller units or lower levels of care. Future iterations could adapt the format for Role 1 or 2 environments by reducing the number of stations while preserving the core training elements. Furthermore, the event relied on access to specialized personnel and equipment, which may not always be feasible in austere settings. Developing a streamlined version focusing on essential tasks could improve accessibility and sustainability across different operational environments.

Participants expressed a preference for this hands-on, competitive training model over traditional didactic instruction. However, further research should compare skill retention rates between the Litter Olympics and other training modalities to validate effectiveness. While peer teaching was a notable strength of the event, structured mentorship from senior medical personnel could further enhance skill acquisition and reinforce best practices.

Conclusions

The Litter Olympics present a reproducible, engaging, and effective method for sustaining medical readiness in a deployed Role 3 setting. By fostering interdisciplinary collaboration and incorporating physical and cognitive stressors, it enhances both individual and team preparedness. Future research should develop standardized, measurable outcome assessments, explore application in diverse deployment settings, and optimize scalability for broader military medical training programs. Standardized evaluation tools should be developed to quantify performance improvements, and the training model should be expanded to include lower levels of care and nonmedical personnel. Structured debriefing sessions would also provide valuable insight into lessons learned and potential refinements. By integrating these enhancements, the Litter Olympics can serve as a cornerstone for maintaining operational medical readiness in deployed environments.

Military medical personnel rely on individual critical tasks lists (ICTLs) to maintain proficiency in essential medical skills during deployments. However, sustaining these competencies in a low-casualty operational setting presents unique challenges. Traditional training methods, such as lectures or simulations outside operational contexts, may lack engagement and fail to replicate the stressors of real-world scenarios. Previous research has emphasized the importance of continuous medical readiness training in austere environments, highlighting the need for innovative approaches.^1,2

The Litter Olympics was developed as an in-theater training exercise designed to enhance medical readiness, foster interdisciplinary teamwork, and incorporate physical exertion into skill maintenance. By requiring teams to carry a patient litter through multiple “events,” the exercise reinforced teamwork within a medical readiness-focused series inspired by an Olympic decathlon. This article discusses the feasibility, effectiveness, and potential impact of the Litter Olympics as a training tool for maintaining ICTLs in a deployed environment.

Program

The Litter Olympics were implemented at a Role 3 medical facility in Baghdad, Iraq, where teams composed of individuals from military occupational specialties (MOSs) and areas of concentration (AOCs) participated. Role 3 facilities provide specialty surgical and critical care capabilities, enabling a robust medical training environment.³ The event was designed to reflect the interdisciplinary nature of deployed medical teams and incorporated hands-on training stations covering critical medical skills such as traction splinting, spinal precautions, patient movement, hemorrhage control, airway management, and tactical evacuation procedures.

Tasks were selected based on their relevance to deployed medical care and their inclusion in ICTLs, ensuring alignment with mission-essential skills. Participants were evaluated on task completion, efficiency, and teamwork by experienced medical personnel. Postexercise surveys assessed skill improvement, confidence levels, and areas for refinement. Future studies should incorporate structured performance metrics, such as pre- and postevent evaluations, to quantify proficiency gains (Table 1).

Five mixed MOS/AOC teams participated in the event, completing the exercise in an average time of 50 minutes (Table 2). Participants reported increased confidence in performing ICTs, particularly in patient movement, hemorrhage control, and airway management. The interdisciplinary nature of the teams facilitated peer teaching and cross-training, allowing individuals to better understand each other’s roles and responsibilities. This mirrors findings in previous studies on predeployment training that emphasize the importance of collaborative, hands-on learning.⁴ The physical aspect of the exercise was well received, as it simulated operational conditions and reinforced endurance in high-stress environments. Some tasks, such as cricothyroidotomy and satellite radio setup, required additional instruction, highlighting areas for improvement in future iterations.

Discussion

The Litter Olympics provide a dynamic alternative to traditional classroom instruction by integrating realistic, scenario-based training. However, several limitations were identified. The most significant was the lack of formalized outcome metrics. While qualitative feedback was overwhelmingly positive, no structured performance assessment tool, such as pre- and postevent skill evaluations, was used. Future studies should incorporate objective measures of competency to strengthen the evidence base for this training model. Additionally, participant feedback suggested that more structured debriefing sessions postexercise would enhance learning retention and provide actionable insights for future program modifications.

Another consideration is the scalability and adaptability of the exercise. While effective in a Role 3 setting, modifications may be required for smaller units or lower levels of care. Future iterations could adapt the format for Role 1 or 2 environments by reducing the number of stations while preserving the core training elements. Furthermore, the event relied on access to specialized personnel and equipment, which may not always be feasible in austere settings. Developing a streamlined version focusing on essential tasks could improve accessibility and sustainability across different operational environments.

Participants expressed a preference for this hands-on, competitive training model over traditional didactic instruction. However, further research should compare skill retention rates between the Litter Olympics and other training modalities to validate effectiveness. While peer teaching was a notable strength of the event, structured mentorship from senior medical personnel could further enhance skill acquisition and reinforce best practices.

Conclusions

The Litter Olympics present a reproducible, engaging, and effective method for sustaining medical readiness in a deployed Role 3 setting. By fostering interdisciplinary collaboration and incorporating physical and cognitive stressors, it enhances both individual and team preparedness. Future research should develop standardized, measurable outcome assessments, explore application in diverse deployment settings, and optimize scalability for broader military medical training programs. Standardized evaluation tools should be developed to quantify performance improvements, and the training model should be expanded to include lower levels of care and nonmedical personnel. Structured debriefing sessions would also provide valuable insight into lessons learned and potential refinements. By integrating these enhancements, the Litter Olympics can serve as a cornerstone for maintaining operational medical readiness in deployed environments.

Military medical personnel rely on individual critical tasks lists (ICTLs) to maintain proficiency in essential medical skills during deployments. However, sustaining these competencies in a low-casualty operational setting presents unique challenges. Traditional training methods, such as lectures or simulations outside operational contexts, may lack engagement and fail to replicate the stressors of real-world scenarios. Previous research has emphasized the importance of continuous medical readiness training in austere environments, highlighting the need for innovative approaches.^1,2

The Litter Olympics was developed as an in-theater training exercise designed to enhance medical readiness, foster interdisciplinary teamwork, and incorporate physical exertion into skill maintenance. By requiring teams to carry a patient litter through multiple “events,” the exercise reinforced teamwork within a medical readiness-focused series inspired by an Olympic decathlon. This article discusses the feasibility, effectiveness, and potential impact of the Litter Olympics as a training tool for maintaining ICTLs in a deployed environment.

Program

The Litter Olympics were implemented at a Role 3 medical facility in Baghdad, Iraq, where teams composed of individuals from military occupational specialties (MOSs) and areas of concentration (AOCs) participated. Role 3 facilities provide specialty surgical and critical care capabilities, enabling a robust medical training environment.³ The event was designed to reflect the interdisciplinary nature of deployed medical teams and incorporated hands-on training stations covering critical medical skills such as traction splinting, spinal precautions, patient movement, hemorrhage control, airway management, and tactical evacuation procedures.

Tasks were selected based on their relevance to deployed medical care and their inclusion in ICTLs, ensuring alignment with mission-essential skills. Participants were evaluated on task completion, efficiency, and teamwork by experienced medical personnel. Postexercise surveys assessed skill improvement, confidence levels, and areas for refinement. Future studies should incorporate structured performance metrics, such as pre- and postevent evaluations, to quantify proficiency gains (Table 1).

Five mixed MOS/AOC teams participated in the event, completing the exercise in an average time of 50 minutes (Table 2). Participants reported increased confidence in performing ICTs, particularly in patient movement, hemorrhage control, and airway management. The interdisciplinary nature of the teams facilitated peer teaching and cross-training, allowing individuals to better understand each other’s roles and responsibilities. This mirrors findings in previous studies on predeployment training that emphasize the importance of collaborative, hands-on learning.⁴ The physical aspect of the exercise was well received, as it simulated operational conditions and reinforced endurance in high-stress environments. Some tasks, such as cricothyroidotomy and satellite radio setup, required additional instruction, highlighting areas for improvement in future iterations.

Discussion

The Litter Olympics provide a dynamic alternative to traditional classroom instruction by integrating realistic, scenario-based training. However, several limitations were identified. The most significant was the lack of formalized outcome metrics. While qualitative feedback was overwhelmingly positive, no structured performance assessment tool, such as pre- and postevent skill evaluations, was used. Future studies should incorporate objective measures of competency to strengthen the evidence base for this training model. Additionally, participant feedback suggested that more structured debriefing sessions postexercise would enhance learning retention and provide actionable insights for future program modifications.

Another consideration is the scalability and adaptability of the exercise. While effective in a Role 3 setting, modifications may be required for smaller units or lower levels of care. Future iterations could adapt the format for Role 1 or 2 environments by reducing the number of stations while preserving the core training elements. Furthermore, the event relied on access to specialized personnel and equipment, which may not always be feasible in austere settings. Developing a streamlined version focusing on essential tasks could improve accessibility and sustainability across different operational environments.

Participants expressed a preference for this hands-on, competitive training model over traditional didactic instruction. However, further research should compare skill retention rates between the Litter Olympics and other training modalities to validate effectiveness. While peer teaching was a notable strength of the event, structured mentorship from senior medical personnel could further enhance skill acquisition and reinforce best practices.

Conclusions

The Litter Olympics present a reproducible, engaging, and effective method for sustaining medical readiness in a deployed Role 3 setting. By fostering interdisciplinary collaboration and incorporating physical and cognitive stressors, it enhances both individual and team preparedness. Future research should develop standardized, measurable outcome assessments, explore application in diverse deployment settings, and optimize scalability for broader military medical training programs. Standardized evaluation tools should be developed to quantify performance improvements, and the training model should be expanded to include lower levels of care and nonmedical personnel. Structured debriefing sessions would also provide valuable insight into lessons learned and potential refinements. By integrating these enhancements, the Litter Olympics can serve as a cornerstone for maintaining operational medical readiness in deployed environments.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

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.