Throughout its history, a major focus of the mission of the US Department of Veterans Affairs (VA) has been to respond to the needs of military personnel returning from war. Given the broad spectrum of potential effects of combat deployment on the health and well-being of service members, VA is oriented toward comprehensive postcombat support, health promotion, disease prevention, and proactive approaches to caring for combat veterans. One goal of such care is to prevent or mitigate chronic health impairments. This article briefly summarizes the health care needs of service members of Operation Enduring Freedom in Afghanistan (OEF), Operation Iraqi Freedom (OIF) (2003-2010), and Operation New Dawn in Iraq (OND) (2010-present); describes VA's role in addressing the needs of combat veterans; and outlines VA's evolving vision for how to apply principles of population health management to ensure prompt, effective, and sustained response to the postdeployment health needs of veterans returning from future conflicts.

Although the impact of OEF/OIF/OND is most visible in the physical injuries sustained on the battlefield, serving in combat areas affects veterans in various ways and results in a wide array of postcombat needs. Seventy-five percent of combat casualties in the current conflicts are due to explosive mechanisms of injury, primarily improvised explosive devices (1). These explosions can result in physical injury to limbs, concussion, traumatic brain injury (TBI), burns, blinding, and hearing loss. Advances in body armor and frontline medical response have increased the survival rate of soldiers with battlefield injuries (2). Sustaining such injuries, witnessing such events, and maintaining constant vigilance for such attacks also carry psychological risk. Cumulative or recurrent physical injuries and psychological traumas, along with the challenges of repetitive transitions between deployed and nondeployed status, are compounded by innumerable concomitant social and economic consequences (3).

Many injured service members have what VA has termed "polytrauma," or multiple injuries from a single event involving a complex array of discrete, often co-occurring, medical conditions with overlapping symptoms (4). Prevalence rates, which provide an inventory of injuries, often do not reveal co-occurrence of conditions, and hence belie the impact of multiple injuries on 1 person. More than 229,000 Armed Forces personnel have been diagnosed as having TBI since 2000 (5), and recent studies found that 10% to 23% of OEF/OIF service members screened positive for TBI (6,7). In the VA as of August 2011, 561,000 OEF/OIF veterans have been screened for TBI, 111,000 had an initial positive screen, and 43,000 had a confirmed TBI diagnosis after a comprehensive evaluation.With regard to mental health concerns, among Army and Marine Corps returnees from Iraq, 27% to 36% meet criteria for the broad definition of a mental health disorder 3 to 6 months after returning from deployment, including depression (10%-13%) and posttraumatic stress disorder (PTSD) (17%-25%) (8). One study found that 37% of OEF/OIF veterans receiving VA health care were diagnosed with a mental health disorder (9). Recent research has focused on the "polytrauma clinical triad," or the co-occurrence of TBI, PTSD, and chronic pain (10). In 1 study at a VA polytrauma site, a review of medical records revealed that 42.1% of the OEF/OIF patient sample were diagnosed with all 3 conditions (11). Those with all 3 conditions are also more likely to experience variability in depressed heart rates and cardiac complications (12). Although the prevalence and impact of auditory and visual impairment is understudied, 1 study of VA OEF/OIF patients found visual impairment ranged from 8.5% to 15.7%; auditory impairment, from 21.0% to 33.0%; and dual sensory impairment, from 22.7% to 35.4%; those with blast exposure had the highest rates (13). Many injured service members are recovering from numerous co-occurring conditions, including TBI, pain, amputation, visual and hearing impairment, aphasia, and PTSD, along with other mental health conditions. Besides physical injuries and mental health disorders, combat exposures increase propensity for engaging in risk behaviors, including excessive and binge drinking, verbal or physical aggression, and seeking dangerous activities (14). Finally, many returning service members face postdeployment challenges with social relationships and community reintegration (3,15). The key to providing care for this cohort of veterans has been to implement a systematic, comprehensive, and integrated approach to needs assessment and care delivery.

The VA approach to health care for combat veterans is based on the standard model of population health management: the use of primary, secondary, and tertiary prevention to optimize health outcomes for OEF/OIF/OND service members (Figure). VA has developed programs and services to respond at all levels of the population health model, from veterans who have sustained devastating physical injuries to those who need and seek nothing more than readjustment advice, and for all of the veterans along that spectrum. This article focuses on the programs specific to veterans returning from Afghanistan and Iraq (Table).

Many efforts are underway for improving VA care for returning combat veterans. All combat veterans can receive no-fee VA care for potentially service-related concerns for 5 years following discharge from active duty. The transition of care from DoD to VA for veterans of the current conflicts is complicated by the fact that half of the members of the military deployed to Iraq and Afghanistan have been members of the Reserve and the National Guard. Many have been deployed more than once and in the process have experienced numerous transitions in care between DoD and VA as they shift in and out of active duty status. To help with these transitions in care, VA and DoD have collaborated on many projects, including creation of a shared medical record system. VA and DoD have developed liaison programs to help service members and their families transition from military treatment facilities to VA facilities, as well as outreach programs for service members who are not seriously injured but who may need help with reintegration. Coordination of care in these transitions between VA and DoD is necessary to avoid gaps in care. When a service member is discharged and becomes a veteran or a National Guard soldier returns home from active duty, VA seeks to begin providing comprehensive care.

VA is a national system of health care with 153 medical centers and more than 900 community-based outreach clinics, but the full range of comprehensive services is geographically dispersed and not available in every veteran's home community. To meet the distance barrier, VA is using new telehealth technologies to bring specialty care closer to the veteran.

VA must provide high-quality, interdisciplinary, integrated care to combat veterans to ensure they recover their optimal health and reintegrate successfully into civilian society and postwar life. VA has developed effective strategies and approaches to serve needs of veterans returning home from war. During times of peace, as an essential part of our national infrastructure of preparedness, these capabilities for postdeployment care must be maintained and ready for activation. Preparing for future conflicts will entail understanding the potential environmental agent or toxic exposures service members may face in fields of combat and remaining abreast of advances in battlefield and military technology. Our postcombat care system must include collaborative relationships among VA, DoD, and other government and community agencies, and integrated records systems to identify and track emerging symptoms, illnesses, and injuries. The system must have training plans to educate VA and community providers on needs of returnees and appropriate screening tools to detect past physical and mental health issues in new contexts. VA's doors should remain open to service members and their families who are struggling with readjustment, and VA should have the capability of quickly putting together a national response that allows recovering veterans to transition seamlessly to civilian life and to do so closer to home. At the center of preparedness for war will be a population-based approach to health recovery that uses interdisciplinary teams for postcombat care.