Stepped Care Approach to the Management of Post-Deployment Health Issues

1. Stepped Care Approach to the Management of Post-Deployment Health Issues Drew A. Helmer, MD, MS Associate Director of Research-PrimeCare Assistant Director, Neurorehabilitation:Neurons to Networks VA Rehabilitation Research & Development Center of Excellence Assistant Professor of Medicine Baylor College of Medicine & the Michael E. DeBakey VA Medical Center Houston, TX

2. Purpose • Advocate for a holistic, efficient, and patient-centered approach to the care of recent combat veterans that proactively assesses for the common and distinct issues of this population.

3. Goals • Summarize the common issues encountered in the healthcare of recent combat veterans. • Describe the essential components of post-deployment care for recent combat veterans. • Describe the continuum of care for deployment health issues.

4. Healthcare Delivery Background

5. Health and Function • Health- is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. • Function- is the ability to perform physiologic functions of body systems, tasks and actions, and involvement in life situations.

6. Healthcare • Healthcare is the delivery of services meant to maintain or improve health and function of an individual. • Value in healthcare is increasingly important • The right care at the right time in the right setting • Stepped-care approach • Team-based approach • Enhanced use of technology • Link care to health and function outcomes

7. Healthcare: A stepped-care approach Inpatient Care Specialty Care Intensity of Healthcare Services Primary Care Patient education/ self-management Public Health Education Disease burden and severity

8. Primary Care • Primary care refers to healthcare delivery that is: • First contact (Accessible) • Comprehensive • Continuous • Coordinated • Patient-centered • Accountable • Patient-Centered Medical Home • Patient Aligned Care Teams (PACTs) • Emphasizes team-based delivery of primary care • Team members function at peak of training and experience.

9. OEF/OIF Veterans in the VHA

10. Deployment of Service-members(2nd Q FY 2011) • Approximately 2.3 million service-members have deployed in support of OEF/OIF • 1,318,510 OEF/OIF Veterans left active duty and are eligible for VA health care since FY 2002 • 712,089 (~54%) Former Active Duty troops • 606,421 (~46%) Reserve and National Guard • 0.23% (5,328) individuals died in-theater

11. VHA Utilization Of 1,318,510eligible OEF/OIF/OND Veterans: • 683,521 (52%) Veterans have obtained VA health care since FY 2002 • 94% seen as outpatients only • 6% have been hospitalized at least once • 431,453 OEF/OIF/OND Veterans accessed VHA care during the past year. • 7% of 6 million VHA users in FY 2010.

12. Demographic Characteristics of OEF, OIF and OND Veterans Utilizing VA Health Care * Percentages reported are approximate due to rounding. † A range of birth years is now being reported rather than a range of ages to capture with greater precision the age distribution of OEF/OIF/OND Veterans utilizing VA health care. This began with the 3rd Qtr FY 2009 report. Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2011

13. Frequency of Diagnoses* among OEF/OIF/OND Veterans *Includes both provisional and confirmed diagnoses. **These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of March 31, 2011; Veterans can have multiple diagnoses with each health care encounter. A Veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 683,521; percentages add up to greater than 100 for the same reason. † Percentages reported are approximate due to rounding. Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2011 13

14. Frequency of Mental Disorders1 among OEF/OIF/OND Veterans since 20022 1 Includes both provisional and confirmed diagnoses. 2 These are cumulative data since FY 2002. ICD diagnoses used in these analyses are obtained from computerized administrative data. Although diagnoses are made by trained health care providers, up to one-third of coded diagnoses may not be confirmed when initially coded because the diagnosis is provisional, pending further evaluation. 3 A total of 349,786 unique patients received a diagnosis of a possible mental disorder. A Veteran may have more than one mental disorder diagnosis and each diagnosis is entered separately in this table; therefore, the total number above will be higher than 349,786. 4 This row of data does not include information on PTSD from VA’s Vet Centers or data from Veterans not enrolled for VA health care. Also, this row does not include Veterans who did not receive a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment reaction (ICD-9 309). 5 This category currently excludes: 94,951 Veterans who only have a diagnosis of tobacco use disorder (ICD-9CM 305.1); 23,587 Veterans who only have a diagnosis of alcohol abuse (ICD-9CM 305.0);and 18,416 Veterans who have diagnoses of both tobacco use disorder and alcohol abuse (ICD-9CM 305.1 and 305.0), but no other ICD-9CM 305 diagnoses. Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2011

15. How Does Combat Affect Health? Physical injuries with residual pain Diagnosable mental health conditions Psychosocial distress: marriage/work/social disruption Unexplained symptoms with general health decline Hearing problems Dental problems Post-war death/injury from “incidental trauma”

16. Jason I am a 23 year old Army combat Veteran. I just returned from Iraq eight months ago after a 13-month deployment as a combat medic in Mosul. I was exposed to more than a dozen IED blasts and was told before my discharge that I have TBI …. I have pretty intense back pain and am on hydrocodone from my military doc. I am feeling irritable, have problems sleeping, have nightmares at least once a week and panic attacks every two or three days. I drink a six pack every night and seem to start earlier all the time. My wife told me that if I don’t get some help, she is taking our 18-month-old child with her and will move out and go live with a friend. I just lost my third job in 6 months. You know, I care but I don’t care. It all sucks, and I cannot turn this off in my head. I do want to sleep if I can do it peacefully and drinking ends up putting me out for a while so it is good for a while. It just doesn’t last long enough. Then the rest of the time it’s the nightmares and memories!!!! I live more than 40 minutes away from the medical center and have difficulty coming up with gas money to make it in. During the initial interview I told them it has gotten to the point where I don’t really care what happens to me … and I really don’t. I am stuck where I am at.

17. Jason’s Concerns • Mild traumatic brain injury • PTSD • Alcohol abuse • Chronic back pain • Financial distress • Relationship problems • Lack of employment • Barriers to healthcare

18. Shalanda I am a 30 year old reservist who was deployed to Iraq for a 12 month tour. I returned to my husband and 3 year old daughter 1 year ago. I haven’t been the same since I returned. I have difficulty focusing at work and I’m afraid I may lose my job due to poor performance. I get tearful almost everyday at the smallest things. I can’t sleep, I am tired all the time. My knees kill me all the time and they swell a little if I walk too much. My mother takes my daughter on the weekends because I can’t handle her tantrums and crying and she’s in daycare while I’m at work. I haven’t been intimate with my husband since I came back and he’s getting impatient with me. I haven’t told him or anybody about the night I had to push a fellow soldier off of me, and then had to work side-by-side with him everyday for another 3 months. I still see him at drill. I tried to get help from my primary care doctor, but he didn’t seem to have time to listen to me, so I just told him I had headaches and got a prescription for them, which helps a little. I don’t know who else to talk to.

19. Shalanda’s Concerns • Depression • Sexual trauma • Musculoskeletal pain • Headaches • Sexual dysfunction • Relationship challenges • Financial stress

21. Veteran-Reported NeedsVISN 16 Focus Groups • Education and jobs • Counseling and other services for family • Better coordination of care • More outreach and education about VA services • Expanded clinic hours

22. Public Health Education • General Message • Some men and women deployed to combat have problems and help is available. • Target Populations • Active duty servicemembers and family • Veterans and family • Challenge- reaching the Veteran community • Only 50% use VHA • Many do not identify as “Veteran” • Risk of stigma • Possible successful strategies • Schools/GI Bill • VBA • DoD alumni activities • Veteran Service Organizations • Online Social Media

23. Post-Deployment Healthcare

24. Post-deployment healthcare:A continuum • Department of Defense • Pre-deployment health assessments • Post-deployment health assessments • Post-deployment health reassessments • Seamless transition • Screening • Core initial assessments • Mental health • Physical health • Psychosocial health • Ongoing primary care • Referral to appropriate specialty assessment and care • Case management • Multidisciplinary assessment and care • Inpatient services • Regional and national referrals

25. Goals of Post-Deployment Care • Smooth entry into VHA • Ease transition from military to civilian life • Identify needs • Provide services to match the needs in a timely and efficient manner • Maximize function and quality of life for patients • Patient satisfaction • Promote the patient-centered medical home

26. ScreeningClinical Reminder- Performance measure or tool? • I&A physical health • Fever • GI symptoms • Rash • Unexplained pain, fatigue, other • Traumatic brain injury • Post-Traumatic Stress Disorder • Depression • Suicidal Ideation • Alcohol misuse • Military Sexual Trauma • Pain • Hepatitis C virus risk factors

27. Screen for infectious diseases and chronic symptoms • Do you have any problems with chronic diarrhea or other gastrointestinal complaints since serving in the area of conflict? - Ova and parasites for giardiasisand amoebiasis • Do you have any unexplained fevers? - Evaluate for malaria, amoeba, and visceral leishmania. • Do you have a persistent papular or nodular skin rash that began after deployment to Southwest Asia? - Examine for cutaneousleishmaniasis. • Have you had any physical symptoms, such as fatigue, headaches, muscle/joint pains, forgetfulness, for three months or longer that have interfered with your normal daily activities at home or work?

28. Screen for Traumatic Brain Injury • During any of your OIF/OEF deployment(s) did you experience any of the following events? • Blast or explosion • Vehicular accident/crash • Fragment wound or bullet wound above the shoulders • Fall • Blow to head • Other injury to head • Did you have any of these symptoms IMMEDIATELY afterwards? • Losing consciousness/”knocked out” • Being dazed, confused or “seeing stars” • Not remembering the event • Concussion • Head Injury • Did any of the following problems begin or get worse afterwards? • Memory problems • Balance problems or dizziness • Sensitivity to bright light • Irritability • Headaches • Sleep problems • In the past week, have you had any of the symptoms from section 3?

29. Screen for Post-traumatic Stress Disorder Have you ever 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?

30. Screen for Depression • Over the past two weeks, how often have you been bothered by the following problems? • Little interest or pleasure in doing things • Feeling down, depressed, or hopeless

31. Screen for Suicidal Ideation • Are you feeling hopeless about the present or the future? • Have you had thoughts of taking your life? • When did you have these thoughts? • Do you have a plan to take your life? • Have you ever had a suicide attempt?

32. Screen for Alcohol Misuse • How often did you have a drink containing alcohol in the past year? • How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? • How often did you have six or more drinks on one occasion in the past year?

33. Screen for Sexual Trauma • While you were on active military duty: • Did you ever receive uninvited or unwanted sexual attention (i.e., touching, cornering, pressure for sexual favors or inappropriate verbal remarks, etc.)? • Did anyone ever use force or threat of force to have sex against your will?

34. Screen for Pain • Pain as the Fifth Vital Sign • Score (0-10) • Site of pain • Is current pain level acceptable to patient? • If no, further evaluation and plan warranted

35. Screen for Hepatitis C Risk • In the past or currently does the patient have any of the recognized risk factors for hepatitis C? • Tattoo/repeated body piercing • Multiple sex partners • Known blood exposure • Intranasal cocaine use • IV drug use

36. Integrated Post-Combat Care Physical Risk: Primary Care Psychological Risk: Mental Health V Psycho-social Risk: Social Work

37. Deployment/Military History • Ask about deployment • “Were you deployed?” Or “Where were you deployed?” • “How was it?” • “Did you have any injuries or health problems while deployed?” • Military history • Component • Branch • Unit • Military Occupational Specialty (MOS) • Deployment dates and locations • Responsibility/Function while deployed • Date of separation/Current military status

38. Physical Health Assessment(Primary Care Vesting) • Elicit Patient Agenda • History of Present Illness • Past Medical History- including psychiatric • Past Surgical History • Military History • Social History- including school, work, relationships, dependents, legal, hobbies • Sexual History- contraception, sexually transmitted disease history & prophylaxis • Medications • Allergies • Family History • Obstetric/Gynecologic History- LMP, gravity/parity, menstrual characteristics • Review of Systems- sleep, weight changes • Vital Signs • Physical Exam- mental status exam, skin, musculoskeletal, back, neurologic • Laboratory- CBC with diff, Urinalysis, comprehensive metabolic panel, HCV, HIV, RPR, TSH, lipid profile • Assessment and Plan

39. Mental Health Assessment • History of present illness • Past psychiatric history • Alcohol, other drug, nicotine, and other addictive behaviors • Family history of addictive behaviors • Childhood history/Attention Deficit Disorders • Social history • Military history • Psychiatric review of systems • Past medical history • Mental Status Exam/Suicide Risk Assessment • DSM IV Diagnosis • Plan

40. Psychosocial Assessment • Medical and Mental Health Challenges • Vocational/Financial • Social Support • Mental health/Emotional/Substance Abuse • Suicidal/Homicidal Ideation • Medication Use/Adherence • Case Management- Yes or No?

41. The Hand Off • At MEDVAMC, the post-deployment clinic is an intake clinic. • Patients are evaluated by the three core disciplines and an initial plan is created. • Patients are assigned to a patient-centered medical home teamlet • Primary care provider • Mental health provider • Social workers/case manager

42. Specialty Care • Case Management • Mental Health • Polytrauma/Traumatic Brain Injury • Physical Medicine and Rehabilitation • Orthopedics • Chiropractor/Acupuncture • Pain Clinic • Dental • Audiology/ENT • VISOR Program (low vision, trauma-related complaints) • Sleep clinic

43. Resources for Post-Deployment Care • Mental health • Polytrauma/Traumatic Brain Injury (PM&R) • Primary care • Social work • OEF/OIF program • DoD partners • Community/Veterans Service Organizations • Veterans Benefits Administration

44. Jason’s Concerns • Mild traumatic brain injury • PTSD • Alcohol abuse • Chronic back pain • Financial distress • Relationship problems • Lack of employment • Barriers to healthcare

45. Shalanda’s Concerns • Depression • Sexual trauma • Musculoskeletal pain • Headaches • Sexual dysfunction • Relationship challenges • Financial stress

46. When primary care isn’t enough-Outpatient • Intensify primary medical, mental health, and social work care • Regular meetings of team for case presentation and discussion • Individual counseling, more frequent visits/phone calls, case management • Intensify local community engagement • School programs • Wounded Warrior Project • LoneStar Veterans Association • Mental Health of America-Houston • Family Services • Vet Centers • Explore DoD resources • Case management • TriCare (or other) health insurance coverage • DoD referral centers and options

47. When primary care isn’t enough-Inpatient • Admit to local programs • ROVER/WISER inpatient mental health • Substance abuse treatment • Neurology long-term monitoring • Physical rehabilitation • Refer to national programs • Residential Mental Health treatment programs • War-Related Illness and Injury Study Centers • Pain Rehabilitation Center • Level 1 or 2 Polytrauma Network Sites

48. Mind the Gap and Close the Loop!!!

49. Tips for Success • Listen to the patient • Elicit the patient’s concerns • Negotiate the patient’s goals • Create a plan with targets and timelines • Engage the family • Work as a cohesive team • Advocate for the patient and his/her goals • Communicate often and effectively • Use technology appropriately

50. Responsibility • EVERYONE will interact with OEF/OIF Veterans. • EVERYONE must be knowledgeable of the life stage and deployment-related needs, concerns, and expectations of OEF/OIF Veterans. • EVERYONE is part of the post-deployment healthcare team. • EVERY Veteran deserves the same high standard of care.