Post-Deployment Health Reassessment PDHRA

1. 1 Post-Deployment HealthReassessment (PDHRA) Clinician Training United States Marine Corps February 2006

2. 2 Background on the Post-Deployment Health Reassessment (PDHRA) Reassessment of the health of all re-deployed service members at 90-180 days post-deployment was ordered by ASD(HA) on 10 March 2005 ASN(M&RA) concurred on 05 July 2005 Implementation guidance for the Marine Corps is contained in two MARADMIN messages due for release in February 2006 The major reason for performing a health reassessment at 3 to 6 months post-deployment is concern over possible delayed mental health problems related to deployment stress All over the world, service men and women are making sacrifices on behalf of this country. There has never been a greater need for us to provide world-class,compassionate healthcare to those service members who are protecting this country. To ensure the health of service members around the world, the Department of Defense monitors and develops health initiatives that address the latest needs facing our service members.All over the world, service men and women are making sacrifices on behalf of this country. There has never been a greater need for us to provide world-class,compassionate healthcare to those service members who are protecting this country. To ensure the health of service members around the world, the Department of Defense monitors and develops health initiatives that address the latest needs facing our service members.

3. 3 PDHRA Key Elements Outreach: Directly asking Marines and Sailors about their health problems after deployment, instead of waiting for them to step forward Education: An educational brief must be delivered to all unit Marines and Sailors around the same time as the PDHRA, preferably immediately before it Health Reassessment: PDHRA is filled out by each Marine and Sailor electronically Detailed Evaluation and Treatment: Face-to face interview of each Marine and Sailor is required, with referral recommendations documented electronically Follow-up and Case Management: Referrals and treatment plans established on the PDHRA must be followed up to ensure compliance and adequacy In a nutshell, the PDHRA works very much like the PDHA, which is currently administered immediately upon return from deployment. Service members will be asked to answer a few screening questions using an electronic or web-enabled questionnaire, and then to discuss their health concerns with a healthcare provider to determine if more detailed diagnostic evaluation, additional treatment, or health-related information is needed. Those of us who have treated service members in the past, know how proud and strong these men and women are. It is vital that we support this initiative and these men and women with a great deal of care and respect.In a nutshell, the PDHRA works very much like the PDHA, which is currently administered immediately upon return from deployment. Service members will be asked to answer a few screening questions using an electronic or web-enabled questionnaire, and then to discuss their health concerns with a healthcare provider to determine if more detailed diagnostic evaluation, additional treatment, or health-related information is needed. Those of us who have treated service members in the past, know how proud and strong these men and women are. It is vital that we support this initiative and these men and women with a great deal of care and respect.

4. 4 Steps in the PDHRA Process Marines who are 90-180 post-deployment are identified by their current commands (including those who deployed with a previous command) Marines fill out the member portions of PDHRA, DD Form 2900, electronically via Naval Environmental Health Center (NEHC) Website Marine is interviewed by medical provider who attends to all positive responses Medical provider documents assessment and referral recommendations also via NEHC Referrals and appointments for medical follow-up are made through routine channels For more service member and medical provider info, see www-nehc.med.navy.mil/PDHA/Users_Guide.pdf All over the world, service men and women are making sacrifices on behalf of this country. There has never been a greater need for us to provide world-class,compassionate healthcare to those service members who are protecting this country. To ensure the health of service members around the world, the Department of Defense monitors and develops health initiatives that address the latest needs facing our service members.All over the world, service men and women are making sacrifices on behalf of this country. There has never been a greater need for us to provide world-class,compassionate healthcare to those service members who are protecting this country. To ensure the health of service members around the world, the Department of Defense monitors and develops health initiatives that address the latest needs facing our service members.

5. 5 PDHRA Overview:General Health (Questions 1-6) Demographics Overall health status Comparison of current health status with pre-deployment health status Injuries, wounds, or assaults during deployment Health care use since return from deployment Current health concerns that service member believes are related to the most recent deployment Questions 1 through 6 cover general, overall health status. These questions give service members an opportunity describe their general health and to voice any concerns they may have.Questions 1 through 6 cover general, overall health status. These questions give service members an opportunity describe their general health and to voice any concerns they may have.

6. 6 Role of Health Care Provider: General Health (Questions 1-6) Develop a sense of service member�s general health through interviewing Review service member�s DD 2795, 2796, and other health records available Refer health concerns identified during interview to Primary Care Provider (PCP) for evaluation and treatment or specialty care if warranted Attend to urgent or emergent care needs You should develop a sense of each service member�s health by reviewing their answers to the general heath questions and interviewing them further about their responses. If the medical records are available, you should compare their responses on the Pre and Post Deployment Health Assessment forms � labeled DD Forms 2795 and 2796. If not available, you can simply ask them about their health status before and after their most recent deployment. For active duty members, general health concerns and conditions that you identify during the interview that need additional assessment beyond the time and circumstances provided for this interview, should be referred to the service member�s Primary Care Provider for further evaluation or treatment under the DoD/VA Post-Deployment Health Clinical Practice Guideline.You should develop a sense of each service member�s health by reviewing their answers to the general heath questions and interviewing them further about their responses. If the medical records are available, you should compare their responses on the Pre and Post Deployment Health Assessment forms � labeled DD Forms 2795 and 2796. If not available, you can simply ask them about their health status before and after their most recent deployment. For active duty members, general health concerns and conditions that you identify during the interview that need additional assessment beyond the time and circumstances provided for this interview, should be referred to the service member�s Primary Care Provider for further evaluation or treatment under the DoD/VA Post-Deployment Health Clinical Practice Guideline.

7. 7 Question 7: �Do you have any persistent major concerns regarding the health effects of something you believe you may have been exposed to or encountered while deployed?� Exposure worry or concern even in absence of symptoms Question 7 is aimed at identifying any major concerns about the potential health effects of things service members believe they were exposed or encountered during this deployment. It�s common for redeploying service members to have concerns about health effects related to biological, chemical, and physical substance or agent exposures that they believe they experienced during deployment.Question 7 is aimed at identifying any major concerns about the potential health effects of things service members believe they were exposed or encountered during this deployment. It�s common for redeploying service members to have concerns about health effects related to biological, chemical, and physical substance or agent exposures that they believe they experienced during deployment.

8. 8 Determine if the service member has concerns Can the concerns be answered by the screening health care provider with information/risk communication tools at hand? If significant health effect, or cannot be answered by screening provider: Refer for follow-up with PCP or specialist Provide information on resources available Role of Health Care Provider: Exposure Concerns (Question 7) Even if they don�t have symptoms now, they may still be concerned that they might suffer long-term health effects, or that their spouses, children, or even their future children may be affected. If they have these concerns, even in the absence of symptoms, they may want to talk with a health care provider to get accurate information about the potential risks or preventive measures they can take. We actually encourage service members to ask their providers for this information rather than relying on less trustworthy sources. You should be sensitive to the fact that they take these concerns very seriously and appreciate direct and candid discussion on the part of their providers.Even if they don�t have symptoms now, they may still be concerned that they might suffer long-term health effects, or that their spouses, children, or even their future children may be affected. If they have these concerns, even in the absence of symptoms, they may want to talk with a health care provider to get accurate information about the potential risks or preventive measures they can take. We actually encourage service members to ask their providers for this information rather than relying on less trustworthy sources. You should be sensitive to the fact that they take these concerns very seriously and appreciate direct and candid discussion on the part of their providers.

9. 9 Resources for Exposure Concerns DoD Deployment Health Clinical Center (DHCC) site: www.pdhealth.mil Naval Environmental Health Center (NEHC): www-nehc.med.navy.mil US Army Center for Health Promotion and Preventive Medicine (USACHPPM) site: chppm-www.apgea.army.mil/ Because your time is limited in this focused encounter, you�ll need to decide whether you can answer their questions at this time, or if a referral is indicated. When discussing occupational or environmental exposures, it�s helpful for you to have access to up to date resources. It�s virtually impossible for a busy clinician to stay current on all information from all deployments. Fortunately, much of this information can be found on the Internet. Good websites for researching exposure concerns include the DoD Deployment Health Clinical Center or DHCC site at www.pdhealth.mil and the US Army Center for Health Promotion and Preventive Medicine or CHPPM website. Fact sheets for both clinicians and service members are available on these sites and can provide answers that address these concerns at the time of the screening. Fact sheets can be printed out for the service member or they can be referred to the website for additional information.Because your time is limited in this focused encounter, you�ll need to decide whether you can answer their questions at this time, or if a referral is indicated. When discussing occupational or environmental exposures, it�s helpful for you to have access to up to date resources. It�s virtually impossible for a busy clinician to stay current on all information from all deployments. Fortunately, much of this information can be found on the Internet. Good websites for researching exposure concerns include the DoD Deployment Health Clinical Center or DHCC site at www.pdhealth.mil and the US Army Center for Health Promotion and Preventive Medicine or CHPPM website. Fact sheets for both clinicians and service members are available on these sites and can provide answers that address these concerns at the time of the screening. Fact sheets can be printed out for the service member or they can be referred to the website for additional information.

10. 10 Mental health screening on PDHRA covers four domains: Interpersonal conflict, adjustment difficulties PTSD Alcohol abuse Depression You must be aware of barriers to acknowledging mental health problems post-deployment Shame over perceived weakness Fear of adverse career repercussions Denial (individual is consciously unaware of even serious stress symptoms) The Mental Health Screening Questions, numbers 8 through 12, are targeted at identifying mental health concerns, adjustment problems, and behavioral risks. The mental health domains covered on the form include depression, post-traumatic stress disorder, alcohol abuse, and interpersonal conflict. Rates of mental health concerns generally are higher for those who experience combat, and rates increase with increased combat exposure.The Mental Health Screening Questions, numbers 8 through 12, are targeted at identifying mental health concerns, adjustment problems, and behavioral risks. The mental health domains covered on the form include depression, post-traumatic stress disorder, alcohol abuse, and interpersonal conflict. Rates of mental health concerns generally are higher for those who experience combat, and rates increase with increased combat exposure.

11. 11 Role of Health Care Provider:Mental Health Question 8 Question 8 : �Since return from your deployment, have you had serious conflicts with your spouse, family members, close friends, or at work that continue to cause you worry or concern?� A positive response to question 8 should be considered a request for help At minimum, refer to counseling services via MCCS, MCCS OneSource, military MTF, VHA, Vet Centers, or pastoral care (depending on responses to other mental health questions) Question 8 inquires about conflicts with spouse, family members, friends, or work. Marriage, family, and relationship problems top the list of reported behavioral health concerns for redeployed service members. For most military members presenting with adjustment concerns, a referral to Military OneSource would be appropriate. Military OneSource is a free service available to all military members, both active and reserve, and their families. It provides for up to six completely confidential preclinical counseling sessions, by phone or in person, along with a wealth of materials that can be accessed on-line or can be received through the mail. Adjustment concerns covered in this program include such issues as re-integration and communication with spouse and family members, financial problems, difficulties in re-adjusting to work, behavior and school problems with children, grief, and other life stress problems. Military OneSource will refer to MTF, Tricare, or VA healthcare providers if more than six sessions are needed, or if the counselors determine that the member has a diagnosable medical problem. Some service members may feel more comfortable talking to their chaplain about grief and spiritual issues. Other family issues can be referred to Family Support, Community Service, or to the Veterans Administration Vet Centers for Guard, Reserve, or separated service members.Question 8 inquires about conflicts with spouse, family members, friends, or work. Marriage, family, and relationship problems top the list of reported behavioral health concerns for redeployed service members. For most military members presenting with adjustment concerns, a referral to Military OneSource would be appropriate. Military OneSource is a free service available to all military members, both active and reserve, and their families. It provides for up to six completely confidential preclinical counseling sessions, by phone or in person, along with a wealth of materials that can be accessed on-line or can be received through the mail. Adjustment concerns covered in this program include such issues as re-integration and communication with spouse and family members, financial problems, difficulties in re-adjusting to work, behavior and school problems with children, grief, and other life stress problems. Military OneSource will refer to MTF, Tricare, or VA healthcare providers if more than six sessions are needed, or if the counselors determine that the member has a diagnosable medical problem. Some service members may feel more comfortable talking to their chaplain about grief and spiritual issues. Other family issues can be referred to Family Support, Community Service, or to the Veterans Administration Vet Centers for Guard, Reserve, or separated service members.

12. 12 Question 9: �Have you had any experience that was so frightening, horrible, or upsetting that, IN THE PAST MONTH, you� Have had any nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that remind you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings? Increasing positive symptoms implies increasing risk of PTSD Overview of PDHRA:PTSD Screening (Question 9) Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.

13. 13 Role of Health Care Provider:PTSD Screening (Question 9) A positive response to any of the four parts of Question 9 requires further questioning: What was/were the upsetting experience(s)? (But do not probe for details.) How long ago did this happen? How did you react at the time of this/these upsetting experience(s)? Listen for evidence of: Terror, horror, or helplessness Dissociation (going �blank� or numb, feeling unreal, etc.) Hyper-arousal Loss of control (physical or emotional) A positive response to any of the four questions on this scale should lead to additional questioning. The current PTSD Clinical Practice Guideline recommends that a report of two or three symptoms would provide increased concern for PTSD.A positive response to any of the four questions on this scale should lead to additional questioning. The current PTSD Clinical Practice Guideline recommends that a report of two or three symptoms would provide increased concern for PTSD.

14. 14 Role of Health Care Provider:PTSD Screening (Question 9) [Cont.] A positive response to any of the four parts of Question 9 also requires careful screening for the cardinal symptoms of PTSD: Intrusive recollections (repetitive nightmares, disturbing daytime images, �flashbacks�) Emotional numbing (lack of usual emotional range and depth) and avoidance of reminders of events Physiological hyper-arousal (difficulty relaxing, insomnia, panic attacks, rage attacks) Also ask how these symptoms have affected the Marine�s ability to do his/her job, relate to family and friends, and maintain peace of mind A positive response to any of the four questions on this scale should lead to additional questioning. The current PTSD Clinical Practice Guideline recommends that a report of two or three symptoms would provide increased concern for PTSD.A positive response to any of the four questions on this scale should lead to additional questioning. The current PTSD Clinical Practice Guideline recommends that a report of two or three symptoms would provide increased concern for PTSD.

15. 15 Role of Health Care Provider:Alcohol Abuse (Question 10) Question 10 assesses for alcohol abuse: In the PAST MONTH, did you use alcohol more than you meant to? In the PAST MONTH, have you felt that you wanted or needed to cut down on your drinking? One positive should lead to additional queries Alcohol abuse is a prevalent problem Supplemental guidance available in Substance Use Disorder Clinical Practice Guideline Guidelines available on www.pdhealth.mil A positive response to any of the four questions on this scale should lead to additional questioning. The current PTSD Clinical Practice Guideline recommends that a report of two or three symptoms would provide increased concern for PTSD.A positive response to any of the four questions on this scale should lead to additional questioning. The current PTSD Clinical Practice Guideline recommends that a report of two or three symptoms would provide increased concern for PTSD.

16. 16 Question 11: �Over the PAST MONTH, have you been bothered by the following problems:� Little interest or pleasure in doing things? Feeling down, depressed, or hopeless? A positive response to either part of Question 11 should prompt inquiry about SIG-E-CAPS depressive symptoms: Sleep problems? Interest loss? Guilt (excessive)? Energy loss? Concentration problems? Appetite changes? Pleasure diminished? Suicidal thoughts or behaviors? Role of Health Care Provider: Depression Screening (Question 11) Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.

17. 17 Question 12: �If you checked off any problems or concerns on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?� Whatever response the Marine gives to Question 12, carefully assess the degree of impairment the symptoms elicited so far have had on: Social functioning Occupational functioning Sense of well-being or hope for the future Any significant functional impairment and loss of well-being should prompt referral Role of Health Care Provider: Functional Impairment (Question 12) Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.

18. 18 Questions 13-16 ask whether the Marine wishes to receive information or be referred to a chaplain, counselor, or healthcare provider for help with identified problems. The decision whether and where to refer should always be made jointly by the Marine and the health care provider doing assessment If the Marine has admitted to significant mental health symptoms but declines referral, ask why. Be alert for denial, minimizing Be alert for fears of career repercussions Be alert for shame and stigma Role of Health Care Provider: Referral Desires (Questions 13-16) Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.

19. 19 Review symptoms and deployment concerns: note whether Marine�s responses were confirmed or amended Ask behavior risk questions (suicidal or homicidal/ assault ideation): assess frequency and severity Conduct risk assessment if SI or HI present or uncertain Record additional concerns elicited during interview Identify specific physical, mental, or exposure concerns and rate severity Check off which referrals will be made Additional comments Provider name and signature Completing the Provider Portion of the PDHRA, Items 1-8 Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.

20. 20 Items 9 and 10 can be filled out by clinical administrative staff, such as corpsmen Item 9: Whether Marine complied with the interview process, and accepted recommended referrals Item 10: Which specific referrals were made Completing the Ancillary/Admin. Portion of the PDHRA Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.Question 9 screens for post-traumatic stress disorder or PTSD. The scale used in this assessment is the primary care PTSD Screen or PC-PTSD.

21. 21 Additional Resources for Clinicians:Medical and Mental Health DoD/VA Clinical Practice Guidelines: www.oqp.med.va.gov/cpg Deployment Health Clinical Center: 866-558-1627, www.pdhealth.mil MyHealthVet: www.myhealth.va.gov National Center for PTSD: www.ncptsd.va.gov MCCS Deployment Support: www.usmc-mccs.org/deploy/ml/index.cfm Naval Environmental Health Center: www-nehc.med.navy.mil Leaders Guide to Managing Marines in Distress: www.usmc-mccs.org/leadersguide/ You record your referral recommendation in Item 6. Individuals who request mental health or community service support may be referred directly to the requested professional. Otherwise, referral to primary care for further evaluation or treatment under the DoD/VA Post-Deployment Health Clinical Practice Guideline is the preferred course of action.You record your referral recommendation in Item 6. Individuals who request mental health or community service support may be referred directly to the requested professional. Otherwise, referral to primary care for further evaluation or treatment under the DoD/VA Post-Deployment Health Clinical Practice Guideline is the preferred course of action.

22. 22 Mental Health Referral Resources Military Medical Treatment Facilities: www.tricare.osd.mil MCCS Counseling Services: at each installation MCCS OneSource: 1-800-869-0278, www.mccsonesource.com (user ID: marines, password: semper fi) Operational Stress Control and Readiness (OSCAR) Teams: at each MEF and/or Division Religious ministry teams: in each unit Vet Centers: www.va.gov/rcs Veterans Health Administration facilities: www.va.gov/directory You record your referral recommendation in Item 6. Individuals who request mental health or community service support may be referred directly to the requested professional. Otherwise, referral to primary care for further evaluation or treatment under the DoD/VA Post-Deployment Health Clinical Practice Guideline is the preferred course of action.You record your referral recommendation in Item 6. Individuals who request mental health or community service support may be referred directly to the requested professional. Otherwise, referral to primary care for further evaluation or treatment under the DoD/VA Post-Deployment Health Clinical Practice Guideline is the preferred course of action.