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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.

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

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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


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


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 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


seen as outpatients only


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)


Unit Type



Active Duty






Birth Year Cohort


1980 – 1995


Air Force


1970 – 1979




1960 – 1969




1950 – 1959




1926 – 1949







* 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


Diagnosis (Broad ICD-9 Categories)**



Infectious and Parasitic Diseases (001-139)



Malignant Neoplasms (140-209)



Benign Neoplasms (210-239)



Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279)



Diseases of Blood and Blood Forming Organs (280-289)



Mental Disorders (290-319)



Diseases of Nervous System/ Sense Organs (320-389)



Diseases of Circulatory System (390-459)



Disease of Respiratory System (460-519)



Disease of Digestive System (520-579)



Diseases of Genitourinary System (580-629)



Diseases of Skin (680-709)



Diseases of Musculoskeletal System/Connective System (710-739)



Symptoms, Signs and Ill Defined Conditions (780-799)


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


Disease Category (ICD 290-319 code)

Total Number of OEF/OIF/OND Veterans


PTSD (ICD-9CM 309.81)



Depressive Disorders (311)


Neurotic Disorders (300)


Affective Psychoses (296)


Alcohol Dependence Syndrome (303)


Nondependent Abuse of Drugs (ICD 305)



Specific Nonpsychotic Mental Disorder due to Organic

Brain Damage (310)


Special Symptoms, Not Elsewhere Classified (307)


Drug Dependence (304)


Sexual Deviations and Disorders (302)



Includes both provisional and confirmed diagnoses.


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.


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.


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).


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


among OEF/OIF/OND Veterans since 2002


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


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


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 stressSlide20

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



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


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


Do you have any unexplained fevers?

- Evaluate for malaria, amoeba, and visceral



Do you have a persistent


or nodular skin rash that began after deployment to Southwest Asia?

- Examine for




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


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


Head Injury

Did any of the following problems begin or get worse afterwards?

Memory problems

Balance problems or dizziness

Sensitivity to bright light



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



Social Work



Mental Health


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




Case management


(or other) health insurance coverage


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


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


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


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


& 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


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