USAF Post-Deployment Health Reassessment Program

1. USAF Post-Deployment Health Reassessment Program James W. Haynes, Lt Col, USAF, MC Chief Consultant, Family Medicine Services Office of the Surgeon General

2. Overview • What is PDHRA? • How did it develop? • What We Kind of Know • Moving Toward DX • Lessons Learned • Where Are We Going?

3. What is PDHRA? • Post-deployment Health Reassessment (DD Form 2900) • OSD/Ha-mandated 10 March 2005 • Standardized Assessment Instrument • Completed 90-180 Days After A Return From Deployment • Includes 16 Questions • Both Physical And Behavioral Health Questions • Healthcare Provider Evaluation (For Positives Only In The Air Force)

4. Why ? • Reports Deployment-related Health Concerns That Emerge Over Time • Enhances Force Health Protection And Readiness Program; Extends Deployment-related Healthcare • Provides A Population Level Health Assessment For Early Identification And Intervention • Demonstrates Caring Posture To Those Who Serve Through Targeted Outreach Procedures • Removes Barriers To Care, De-stigmatize Care-seeking At All Levels ….An Opportunity To Engage Unaddressed Health Care Needs…

5. Timeline ? Over 39,056 PDHRAs Completed! Beta-Test at Seymour Johnson AF/SGO Memo PDHRA User’s Guide and Kx Site Developed Team Formed Web App Developed AF/CVA Memo UDM Roster Site Created AF/SGO Memo for Contract Hires OCT NOV DEC JAN FEB MAR APR MAY JAN 07 2005 2006

6. ADAF Member Returns from Deployment UDM Notifies Member to Complete PDHRA DD Form 2900 at 90 days Is the Member on PRP? YES NO * Member Completes PDHRA in Clinic Member Completes PDHRA Online Is PDHRA Positive *PCE Completes Page 4 of the DD Form 2900 Electronically in PIMR for Positives YES NO PDHRA Monitor Contacts Member’s PCE and Sends PDHRA Results MTF Places PDHRA DD Form 2900 in the Member’s Medical Record *PCE Completes Page 4 of the PDHRA DD Form 2900 Electronically in PIMR END PHSD UM Role: Contact UDM and at 120 & 150 day mark if PDHRA is not yet completed PHSD UM Role: Check to see if PDHRA is reviewed within a duty day; Check to see if Page 4 is completed NLT 30 days • * The MTF will use their standard of care to evaluate and treat PDHRA positive members.

7. Additional Question Sets • Alcohol Use Disorders Identification Test (AUDIT) • 10-item Screening Questionnaire • A Score Of 8 Or More Is Associated With Harmful Or Hazardous Drinking • A Score Of 13 Or More In Women, And 15 Or More In Men, Is Likely To Indicate Alcohol Dependence • Post Traumatic Stress Disorder (PTSD) Checklist-military Version (PCL-M) • Standardized Self-report Rating Scale For PTSD Comprising 17 Items That Correspond To The Key Symptoms Of PTSD • Modified Patient Health Questionnaire (PHQ-9) • Brief 9-item Patient Self-report Depression Assessment With Question 9 About Suicidal Ideation Removed From The Web-application

8. PDHRA Completion Rate For Current ADAF As Of 26 Jan 07 77% 50,984 Total * Excludes members who have separated or retired

9. Screener: Percent ADAF Positive Total = 42,492 NOT POSITIVE 24,490 (58%) POSITIVE 18,002 (42%)

10. Page 4 Compliance Metric: ADAF Compliance Overall: Compliance Within 30 Days:

11. Types of Positives: ADAF PHYSICAL ONLY 7,254 (40.3%) PHYSICAL & MENTAL 6,972 (38.7%) MENTAL ONLY 3,776 (21%) Total = 18,002

12. Screener Symptom Type*: ADAF *Multiple Responses Possible

13. Moving Toward A Diagnosis • Included in analysis if 4 conditions were met: • Arrived in the theater ≥ July 1st, 2004 • Departed from theater ≤ Mar 31st 2006 • Were ADAF 6 months prior to deployment and 6 months after • Had no other deployment 12 months prior and 6 months after • 41,712 met the criteria • All outpatient diagnoses are included (not just primary) Active Duty 6 Months 6 Months 6 Months 01-Jul-04 01-Jan-04 31-Mar-06 30-Sep-06 DEPLOYMENT PERIOD

14. Infectious and parasitic Neoplasms Endocrine, Nutritional, Metabolic, Immune Blood Mental Health* Nervous/Sense Circulatory Respiratory Digestive Genitourinary Pregnancy/Childbirth Skin/Subcutaneous Musculoskeletal/Connective Congenital Perinatal Ill-Defined Injury/Poisoning ICD-9-CM Appendix E Groupings * Mental Uncovered Using Comprehensive Behavioral Health ICD-9 Groupings (CBHIG)

15. Overview of Results: ICD-9-CM Groupings MostPrevalent Post-Deployment Groupings Musculoskeletal / Connective Nervous / Sensory Respiratory Ill-Defined Injury / Poisoning Skin / Subcutaneous

16. Musculoskeletal / Connective

17. Nervous / Sensory

18. Respiratory

19. Ill-Defined

20. Injury / Poisoning

21. Skin / Subcutaneous

22. Infectious and parasitic Neoplasms Endocrine, Nutritional, Metabolic, Immune Blood Mental Health Nervous/Sense Circulatory Respiratory Digestive Genitourinary Pregnancy/Childbirth Skin/Subcutaneous Musculoskeletal/Connective Congenital Perinatal Ill-Defined Injury/Poisoning V1-9       Communicable V10-19   Personal/family history V20-29   Reproductive/development services V30-39   Liveborn infants V40-49   Condition influencing health V50-59   Procedure/aftercare services V60-69   Services Other circumstances V70-85   Exam-No diagnosis Insert list of groups Comprehensive Behavioral Health ICD-9-CM Groupings (CBHIG)

23. Overall Mental Health

24. Overview of Results: CBHIG MostPrevalent Post-Deployment Mental Groupings Tobacco Depression Anxiety Adjustment Alcohol Dx Deferred / NK

25. Tobacco

26. Depression

27. Anxiety Includes PTSD

28. Adjustment

29. Alcohol

30. Dx Deferred / NK

31. PTSD: ICD-9-CM = 309.81

32. Screener: ADAF Enlisted Endorsing ≥ 3 PTSD Symptoms

33. Screener: ADAF Officer Endorsing ≥ 3 PTSD Symptoms

34. V-Code Counseling: Overall

35. Study Takeaways • Utilization Of Mental Health Resources Increases Post Deployment • Prevalence Anxiety Disorders Doubles Post Deployment • Overall Anxiety Diagnoses Relatively Low • AF Focus: Total Continuum of Deployment-Related Mental Health Disorders

36. Lessons Learned Feedback From The Field • Questionnaire Is Too Sensitive • Unit Level Deployment Monitor’s Difficult To Identify Clinical Care Issues • Positive PDHRA but Member Refuses Further Evaluation? • “Burden” On Thinly-stretched Fam Med/Flight Surgeon Shops • Can Direct Referrals Be Made To LSSC For BH + Only? Answer What You Can Early… Someone Else Is Bound To Ask

37. Future • Caution - “Mission Drift”------ Are We Missing The Continuum? • Data Base Is Evolving --- Improvement In Collection/Analysis • Process Based Measures (# Referrals, Types Of Referrals, Etc) • Outcomes Data (Dx, Tx Measures, Better Or Not?) • Moving Toward Diagnoses --- Targets For Prevention And Treatment • “Compliance” Standards For Contacting Members • Who Are The “Refusal To Take” Group? • Improve Total Force Continuum Of Care (ANG, AFRC, AD, VA)

38. Useful Links • PDHRA Form: https://www.afchips.brooks.af.mil/phdra • PHSD PDHRA Knowledge Junction: https://kx.afms.mil/pdhra • PDHealth PDHRA Page: http://www.pdhealth.mil/dcs/pdhra.asp • PDHRA Provider Training: http://www.pdhealth.mil/dcs/BlueSky/index.html • AMSA Status Report: https://www.afchips.brooks.af.mil/PIMR/AMSA_Update.HTM • Compliance Stats on AFCHIPs: https://www.afchips.brooks.af.mil/main.htm

41. BACKUP SLIDES

42. GWOT $$s Used to Fund Behavioral Health Consultants at 37 Bases • Anticipated/Sold With Expectation They May Be Able To Help With PDHRA Processing In Addition To Other Duties • Initial Plan: Hire Civilian For Life Skills Support Center (Lssc) To Allow Blue-suiter To Serve As BHC In The PCE And Facilitate PDHRA Process Along With Other Bhc Roles • Almost All 37 Bases Now Have Contracts In Place, And Money Obligated, With The Expectation That Hires Will Be In Place Late July/August

43. Air Force Bases with Most Deploying Personnel since 1 January 2003 Counts unique deployers* AD = Active Duty - RG = Reserve/Guard

44. Who was included in the sample for analyses? Original Total 139,340 ANG/AFRC -36,303 103,037 Don’t Meet 4 Conditions - 61,325 Sample Total 41,712

45. CBHIG: V-Codes Counseling