Drew A Helmer MD MS Associate Director of Research PrimeCare Assistant Director NeurorehabilitationNeurons to Networks VA Rehabilitation Research amp Development Center of Excellence Assistant Professor of Medicine ID: 731080
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Slide1
Stepped Care Approach to the Management of Post-Deployment Health Issues
Drew A. Helmer, MD, MSAssociate Director of Research-PrimeCareAssistant Director, Neurorehabilitation:Neurons to Networks VA Rehabilitation Research & Development Center of ExcellenceAssistant Professor of MedicineBaylor College of Medicine & the Michael E. DeBakey VA Medical CenterHouston, TXSlide2
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.Slide3
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.Slide4
Healthcare Delivery BackgroundSlide5
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.Slide6
Healthcare
Healthcare is the delivery of services meant to maintain or improve health and function of an individual.Value in healthcare is increasingly importantThe right care at the right time in the right settingStepped-care approachTeam-based approachEnhanced use of technologyLink care to health and function outcomesSlide7
Healthcare: A stepped-care approach
Disease burden and severity
Intensity of Healthcare Services
Public Health Education
Patient education/ self-management
Primary Care
Specialty Care
Inpatient CareSlide8
Primary Care
Primary care refers to healthcare delivery that is:First contact (Accessible)ComprehensiveContinuousCoordinatedPatient-centeredAccountablePatient-Centered Medical Home
Patient Aligned Care Teams (PACTs)
Emphasizes team-based delivery of primary care
Team members function at peak of training and experience.Slide9
OEF/OIF Veterans in the VHASlide10
Deployment of Service-members(2
nd Q FY 2011)Approximately 2.3 million service-members have deployed in support of OEF/OIF1,318,510 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-theaterSlide11
VHA Utilization
Of 1,318,510 eligible 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.Slide12
Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2011
12Demographic Characteristics of OEF, OIF and OND Veterans Utilizing VA Health Care
% OEF/OIF/OND Veterans*
(n = 683,521)
% OEF/OIF/OND Veterans*
(n = 683,521)
Sex
Unit Type
Male
88.1
Active Duty
54.7
Female
11.9
Reserve/Guard
45.3
Birth Year Cohort
†
Branch
1980 – 1995
45.3
Air Force
12.3
1970 – 1979
26.3
Army
61.2
1960 – 1969
21.0
Marines
13.5
1950 – 1959
6.4
Navy
12.9
1926 – 1949
1.0
Rank
Enlisted
91.2
Officer
8.8
* 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.Slide13
Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2011
13
Diagnosis (Broad ICD-9 Categories)**
Frequency
Percent
†
Infectious and Parasitic Diseases (001-139)
101,158
14.8
Malignant Neoplasms (140-209)
8,822
1.3
Benign Neoplasms (210-239)
41,121
6.0
Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279)
207,196
30.3
Diseases of Blood and Blood Forming Organs (280-289)
23,096
3.4
Mental Disorders (290-319)
349,786
51.2
Diseases of Nervous System/ Sense Organs (320-389)
294,433
43.1
Diseases of Circulatory System (390-459)
139,318
20.4
Disease of Respiratory System (460-519)
173,560
25.4
Disease of Digestive System (520-579)
242,070
35.4
Diseases of Genitourinary System (580-629)
96,624
14.1
Diseases of Skin (680-709)
139,159
20.4
Diseases of Musculoskeletal System/Connective System (710-739)
377,205
55.2
Symptoms, Signs and Ill Defined Conditions (780-799)
341,019
49.9Injury/Poisonings (800-999)190,188 27.8Frequency 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.Slide14
Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2011
14
Disease Category (ICD 290-319 code)
Total Number of OEF/OIF/OND Veterans
3
PTSD (ICD-9CM 309.81)
4
187,133
Depressive Disorders (311)
139,119
Neurotic Disorders (300)
118,591
Affective Psychoses (296)
83,575
Alcohol Dependence Syndrome (303)
38,749
Nondependent Abuse of Drugs (ICD 305)
5
26,636
Specific Nonpsychotic Mental Disorder due to Organic
Brain Damage (310)
24,033
Special Symptoms, Not Elsewhere Classified (307)
23,276
Drug Dependence (304)
19,711
Sexual Deviations and Disorders (302)
19,620
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.
Frequency of Mental Disorders
1
among OEF/OIF/OND Veterans since 2002
2Slide15
How Does Combat Affect Health?
Physical injuries with residual painDiagnosable mental health conditionsPsychosocial distress: marriage/work/social disruptionUnexplained symptoms with general health decline Hearing problems
Dental problems
Post-war death/injury from “incidental trauma”Slide16
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.Slide17
Jason’s Concerns
Mild traumatic brain injuryPTSDAlcohol abuseChronic back painFinancial distressRelationship problemsLack of employmentBarriers to healthcareSlide18
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.Slide19
Shalanda’s Concerns
DepressionSexual traumaMusculoskeletal painHeadachesSexual dysfunctionRelationship challengesFinancial stressSlide20Slide21
Veteran-Reported NeedsVISN 16 Focus Groups
Education and jobsCounseling and other services for familyBetter coordination of careMore outreach and education about VA servicesExpanded clinic hoursSlide22
Public Health Education
General MessageSome men and women deployed to combat have problems and help is available.Target PopulationsActive duty servicemembers and familyVeterans and familyChallenge- reaching the Veteran communityOnly 50% use VHAMany do not identify as “Veteran”Risk of stigmaPossible successful strategies
Schools/GI Bill
VBA
DoD
alumni activities
Veteran Service Organizations
Online Social MediaSlide23
Post-Deployment HealthcareSlide24
Post-deployment healthcare:A continuum
Department of DefensePre-deployment health assessmentsPost-deployment health assessmentsPost-deployment health reassessmentsSeamless transitionScreeningCore initial assessmentsMental healthPhysical healthPsychosocial health
Ongoing primary care
Referral to appropriate specialty assessment and care
Case management
Multidisciplinary assessment and care
Inpatient services
Regional and national referralsSlide25
Goals of Post-Deployment Care
Smooth entry into VHAEase transition from military to civilian lifeIdentify needsProvide services to match the needs in a timely and efficient mannerMaximize function and quality of life for patientsPatient satisfactionPromote the patient-centered medical homeSlide26
ScreeningClinical Reminder- Performance measure or tool?
I&A physical healthFeverGI symptomsRashUnexplained pain, fatigue, otherTraumatic brain injuryPost-Traumatic Stress DisorderDepressionSuicidal IdeationAlcohol misuseMilitary Sexual Trauma
Pain
Hepatitis C virus risk factorsSlide27
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 giardiasis and
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
cutaneous
leishmaniasis
.
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?Slide28
Screen for Traumatic Brain Injury
During any of your OIF/OEF deployment(s) did you experience any of the following events?Blast or explosionVehicular accident/crashFragment 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?Slide29
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?Slide30
Screen for Depression
Over the past two weeks, how often have you been bothered by the following problems?Little interest or pleasure in doing thingsFeeling down, depressed, or hopelessSlide31
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?Slide32
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?Slide33
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?Slide34
Screen for Pain
Pain as the Fifth Vital SignScore (0-10)Site of painIs current pain level acceptable to patient?If no, further evaluation and plan warrantedSlide35
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 piercingMultiple sex partnersKnown blood exposureIntranasal cocaine useIV drug useSlide36
Integrated Post-Combat Care
Physical Risk:
Primary Care
Psycho-social
Risk:
Social Work
Psychological
Risk:
Mental Health
VSlide37
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 historyComponentBranchUnitMilitary Occupational Specialty (MOS)Deployment dates and locationsResponsibility/Function while deployed
Date of separation/Current military statusSlide38
Physical Health Assessment(Primary Care Vesting)
Elicit Patient AgendaHistory of Present IllnessPast Medical History- including psychiatricPast Surgical HistoryMilitary HistorySocial History- including school, work, relationships, dependents, legal, hobbiesSexual History- contraception, sexually transmitted disease history & prophylaxisMedicationsAllergies
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 PlanSlide39
Mental Health Assessment
History of present illnessPast psychiatric historyAlcohol, other drug, nicotine, and other addictive behaviorsFamily history of addictive behaviorsChildhood history/Attention Deficit DisordersSocial historyMilitary historyPsychiatric review of systemsPast medical historyMental Status Exam/Suicide Risk AssessmentDSM IV DiagnosisPlanSlide40
Psychosocial Assessment
Medical and Mental Health ChallengesVocational/FinancialSocial SupportMental health/Emotional/Substance AbuseSuicidal/Homicidal IdeationMedication Use/AdherenceCase Management- Yes or No?Slide41
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 teamletPrimary care providerMental health providerSocial workers/case managerSlide42
Specialty Care
Case ManagementMental HealthPolytrauma/Traumatic Brain InjuryPhysical Medicine and RehabilitationOrthopedicsChiropractor/AcupuncturePain ClinicDentalAudiology/ENTVISOR Program (low vision, trauma-related complaints)Sleep clinicSlide43
Resources for Post-Deployment Care
Mental healthPolytrauma/Traumatic Brain Injury (PM&R)Primary careSocial workOEF/OIF programDoD partnersCommunity/Veterans Service OrganizationsVeterans Benefits AdministrationSlide44
Jason’s Concerns
Mild traumatic brain injuryPTSDAlcohol abuseChronic back painFinancial distressRelationship problemsLack of employmentBarriers to healthcareSlide45
Shalanda’s Concerns
DepressionSexual traumaMusculoskeletal painHeadachesSexual dysfunctionRelationship challengesFinancial stressSlide46
When primary care isn’t enough-Outpatient
Intensify primary medical, mental health, and social work careRegular meetings of team for case presentation and discussionIndividual counseling, more frequent visits/phone calls, case managementIntensify local community engagementSchool programsWounded Warrior ProjectLoneStar Veterans AssociationMental Health of America-Houston
Family Services
Vet Centers
Explore
DoD
resources
Case management
TriCare
(or other) health insurance coverage
DoD
referral centers and optionsSlide47
When primary care isn’t enough-Inpatient
Admit to local programsROVER/WISER inpatient mental healthSubstance abuse treatmentNeurology long-term monitoringPhysical rehabilitationRefer to national programsResidential Mental Health treatment programsWar-Related Illness and Injury Study CentersPain Rehabilitation CenterLevel 1 or 2
Polytrauma
Network SitesSlide48
Mind the Gap
and Close the Loop!!!Slide49
Tips for Success
Listen to the patientElicit the patient’s concernsNegotiate the patient’s goalsCreate a plan with targets and timelinesEngage the familyWork as a cohesive teamAdvocate for the patient and his/her goalsCommunicate often and effectivelyUse technology appropriatelySlide50
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.Slide51
How do we know we’re doing the right thing?Slide52
The Ideal Outcome Measure for Post-Deployment Healthcare
Disease-specific vs. GlobalSubjective vs. ObjectiveComprehensive vs. FocusedLength and ease of administrationSensitivity to changeSlide53
Existing Measures
Medical Outcomes Study Short Form 36 (Veterans Rand 36)EuroQoL 5Mayo-Portland Adaptability InventorySydney Psychosocial Reintegration QuestionnaireCommunity Integration QuestionnaireSlide54
Assessing Outcome in Clinical Practice
Function oriented“How are you doing overall?”“How is your school/work/family life/social life going?”“How are your grades/job performance/relationships with partner/kids/friends/extended family?”Watch for changesIncreased frequency/urgency of visits or callsChanging employment situationEntering/dropping out of schoolNew additions to family/care responsibilitiesGrooming, style of dress, attitude
Ask questions about changesSlide55
We need more answers- NOW!
The importance of post-deployment health researchSlide56
Neurorehabilitation:Neurons
to Networks Rehabilitation Research & Development Center of ExcellenceFocus on mild traumatic brain injuryCurrent ProjectsNeuroimaging Assessment of temporal perceptionGenetic predisposition/protective factors
Outcome measures
Virtual reality treatment for
mTBI
& alcohol abuse
Home for post-deployment health research at MEDVAMCSlide57
Other Research Questions
REDUCED EXERCISE TOLERANCE/DYSPNEA- Epidemiologic/clinical studies of risk factorsHEADACHE- Best practices and outcomes of assessment and treatmentCOGNITIVE SYMPTOMS- Pharmacologic interventions in Veterans with mTBI and PTSDELEVATED BLOOD PRESSURE- Longitudinal study of assessment and treatment in young combat veterans with PTSDBACK & KNEE PAIN- Best practices and outcomes of assessment and treatmentSlide58
Summary
OEF/OIF/OND Veterans have special needs related to their military service and life-stage.An integrated, patient-centered, team-based approach to care can effectively address these needs.A continuum of care is available to match intensity of need.Slide59
Contact Information
Drew A. Helmer, MD, MSMEDVAMC, 2002 Holcombe Blvd (153TBI), Houston, TX 77030Drew.helmer@va.govPhone 713-791-1414 x 7010