DoD-VA CLINICAL PRACTICE GUIDELINE ON

POST-DEPLOYMENT HEALTH POST-DEPLOYMENT HEALTH EVALUATION & MANAGEMENTEVALUATION & MANAGEMENT

DoD-VA CLINICAL PRACTICE GUIDELINE ON

POST-DEPLOYMENT HEALTH POST-DEPLOYMENT HEALTH EVALUATION & MANAGEMENTEVALUATION & MANAGEMENT

Uniformed Services UniversityUniformed Services University

Agent Orange

PTSD

Battle fatigue

Neurocirculatory asthenia

Shell shock

Effort syndrome

Da Costa’s syndrome

Soldier’s heart

Gulf War Syndrome

Recent Unexplained Illnesses Involving Recent Unexplained Illnesses Involving the Military, War, Disaster, or Terrorismthe Military, War, Disaster, or Terrorism

Dutch peacekeepers in Dutch peacekeepers in Lebanon (1980s)Lebanon (1980s)

““Jungle Disease” (Dutch Jungle Disease” (Dutch peacekeepers in peacekeepers in Cambodia)Cambodia)

Gulf War SyndromeGulf War Syndrome

Dutch peacekeepers in Dutch peacekeepers in Bosnia (1995-6)Bosnia (1995-6)

Canadian peacekeepers in Canadian peacekeepers in Croatia (late 1990s)Croatia (late 1990s)

Balkan War SyndromeBalkan War Syndrome

Agent Orange ConcernsAgent Orange Concerns

Illnesses after anthrax Illnesses after anthrax vaccination (1990s)vaccination (1990s)

Afghanistan Syndrome Afghanistan Syndrome (Russia, 1990s)(Russia, 1990s)

Chechnya Syndrome Chechnya Syndrome (Russia, 1990s)(Russia, 1990s)

Illnesses after 1992 El Al Illnesses after 1992 El Al Airliner crash in AmsterdamAirliner crash in Amsterdam

Illnesses after WTC attackIllnesses after WTC attack

Lingering anthrax Lingering anthrax symptomssymptoms

Irradiated mail concernsIrradiated mail concerns

Exposure concerns at K-2 Exposure concerns at K-2 (Uzbekistan)(Uzbekistan)

Operation Iraqi Freedom?Operation Iraqi Freedom?

4 Apr 03 UNCLASSIFIED 6

Reserve Component

Medical Screening for Redeploying SoldiersMed Threat Debriefing

CPG**RC Referral

ADME90 d

aysAD Referral

TRICAREDirectCare

Feds Heal

Active ComponentActive Guard and Reserve

TB Skin Test*

InTheater Redeploy

Visit with Provider:-Review DD 2796

-Review deployment exposures-Mental health exam

Complete DD 2796

TB Skin Test*

Repository Blood Specimen

Release fromActive Duty

Provider = Physician, PA, or Nurse-Practitioner

Specific issues the Provider must review in addition to reviewing the DD 2796

Blood specimen required for all personnel

**Clinical Practice Guideline *Two visits, 48-72 hours apart

Overview of Guideline Features

Military-unique vital sign Stepped care framework Risk communication guidance Web-based clinician support Longitudinal care emphasis Data automation features Metrics & outcomes monitoring Supporting ‘center of excellence’

Military Unique Vital Sign

“Is your concern or problem today Is your concern or problem today related to deployment?related to deployment?” (yes-no- (yes-no-maybe)maybe)

all contacts except wellness visits (e.g., periodic examinations, preventive care)

patient rather than clinician determination

< 1% of patients say ‘yes’

Visit for Deployment Related Concern

ICD-9-CM visit code: v70.5_ _6 Definition:

“A visit used to evaluate, clarify, treat, or provide information regarding one or more patient or provider based post-deployment health concerns.”

“This code does not necessarily establish or imply causality between any of the provider’s diagnoses and any particular deployment.”

ICD-9-CM visit code: v70.5_ _6

Code in primary diagnosis position for deployment health concerns and for routine post-deployment (“demob”) exams

Code medical conditions in secondary (non-primary) diagnosis positions.

“E&M Codes” will be used to differentiate demob exams from CPG exams.

Complete PASBA coding guidance available on PDHealth.mil & MEDCOM QM Directorate websites – inform coders & UM people

Unconcerned, Recently Deployed

Concerned, Asymptomatic

Concerned,Recognized

Disease

Concerned,IdiopathicSymptoms

Stepped Risk Communication

Unconcerned, Recently Deployed

Concerned,Recognized

Disease

Concerned,IdiopathicSymptoms

Stepped Risk Communication

Concerned, Concerned, AsymptomaticAsymptomatic

Web-based educ-Web-based educ- ation ation30 minute follow-up30 minute follow-up visit visit

The Asymptomatic Patient with Health Concerns

ICD-9-CM code: ICD-9-CM code: v70.5_ _6 plus v65.5 v70.5_ _6 plus v65.5 Expresses a health concern, but does not exhibit or describe any discernable illness or injury

Concerns related to Illness Exposure An experience News media coverage Another information source

PDHealth.milPDHealth.milWorld Wide Web Support

for Post-Deployment Health Care

Designed For Federal & Civilian Clinicians, Soldiers, & Their Families

Unconcerned, Recently Deployed

Concerned, Asymptomatic

Concerned,IdiopathicSymptoms

Stepped Risk Communication

Concerned, Concerned, Recognized DiseaseRecognized Disease

Disease-centered Disease-centered patient education patient educationDisease prognosisDisease prognosisDisease treatmentDisease treatment options options

ICD-9-CM Coding for Identifiable Disease

v70.5_ _6 v70.5_ _6 plusplus

usual disease codeusual disease code

Unconcerned, Recently Deployed

Concerned, Asymptomatic

Concerned,Recognized

Disease

Stepped Risk Communication

Symptom-based patient Symptom-based patient education educationConsult Deployment HealthConsult Deployment Health Clinical Center Clinical CenterConsider Specialized Care Consider Specialized Care Program Program

Concerned,Concerned,IdiopathicIdiopathicSymptomsSymptoms

Medically Unexplained Symptoms (MUS)

Physical symptoms that provoke care-seeking, but have no clinically determined pathogenesis after an appropriately thorough diagnostic evaluation.”

ICD-9-CM - ICD-9-CM - v70.5_ _6 v70.5_ _6 plusplus 799.8 (MUS Code)799.8 (MUS Code)

A DoD Center of ExcellenceA DoD Center of ExcellenceDeployment Health Clinical Center

& Specialized Care Program

For AssistanceFor AssistanceFor AssistanceFor Assistance

DoD Deployment Health Clinical CenterDoD Deployment Health Clinical Center866-559-1627 866-559-1627

Walter Reed Army Medical CenterWalter Reed Army Medical Center 202-782-6563202-782-6563

Building 2, Room 3G04Building 2, Room 3G04 DSN: 662DSN: 662

6900 Georgia Ave, NW6900 Georgia Ave, NWpdhealth@na.amedd.army.milpdhealth@na.amedd.army.mil

Washington, DC 20307-5001Washington, DC 20307-5001

DoD Deployment Health Clinical CenterDoD Deployment Health Clinical Center866-559-1627 866-559-1627

Walter Reed Army Medical CenterWalter Reed Army Medical Center 202-782-6563202-782-6563

Building 2, Room 3G04Building 2, Room 3G04 DSN: 662DSN: 662

6900 Georgia Ave, NW6900 Georgia Ave, NWpdhealth@na.amedd.army.milpdhealth@na.amedd.army.mil

Washington, DC 20307-5001Washington, DC 20307-5001