RESPECT-MilRe-Engineering Systems for the

Primary Care Treatment of Depression and PTSD in the Military

2They Gave so Selflessly

The RESPECT-Mil Team at Fort Campbell

3

Presenting Today:

MAJ Anthony Rhea MSN, FNP, Primary Care Champion, RESPECT Mil

Dr. Jennifer Hanley DNP, Behavioral Health Champion, RESPECT Mil

Robin Slone RN BS, Lead RESPECT Mil Care Facilitator

The RESPECT-Mil Team at Fort Campbell

Continued

4

CARE FACILITATORS:

Ms. Brenda Tanner RN, BSN (Ashau Valley Clinic)

Mrs. Kathy Parish RN, BSN (Bastogne Clinic)

Mrs. Tina Robertson RN (Aviation Health Clinic)

Mrs. Desiree Allen RN (Blue & White Clinic)

AMINISTRATIVE ASSISTANTS: Mrs. Maria Matta AAMrs. Charity King AA

Mrs. LaShanda Harrison AA

Blanchfield Army Community Hospital Fort Campbell, KY

Home of the Screaming Eagles101st Airborne Division

LaPointe Health Clinic(Ashau Valley & Bastogne)

Aviation Health Clinic Carentan Health Clinic

Blanchfield Army Community Hospital, Fort Campbell, KY

Blue andWhite Clinics

Statistics Fort Campbell, KY is home to 30,000

Soldiers including the 101st Airborne Div, 5th SFG, 86th CSH and the 160th Aviation Regiment

In 2008, 140 Soldiers committed suicide military-wide

In 2009, (first 5 months), there were

67 possible Soldier suicides, 17 of those from Fort Campbell, KY

RESPECT- MilProgram from the Office of the Surgeon

GeneralFt. Campbell – One of 22 Army

Installations worldwide with the RESPECT Mil program

Implementation- March 2008 in one clinic (Carentan)

Presently, six clinics successfully operating which makes the program available in all Soldier Health Services Clinics at Fort Campbell, KY

Current Status of ProgramGoal

Clinics= 6(Carentan, Bastogne, Ashau, AHC,

Blue, White)

RCFs (RN) = 5Admin Assist (AA) = 3Training: All PCMsTraining: Support staff

Current Status6 Clinics5 RCF’s (RNs)3 AA 60+ Providers

trained50+Medics trained70+ Nurses trained

Patie

nt Visits

Patie

nt Scr

eened

Positiv

e Sc

reen

s

Pos. s

ent t

o Tre

atm

ent

0500

10001500200025003000

2762 2662

371149

March- July 2008

Mar Apr May Jun Jul0

2

4

6

8

10

6

10

34

33

5

2

0 01 1

01 1

Low IntermediateHigh

Suicide Risk Level

Statistics

Patie

nt Visits

Patie

nt Scr

eened

Positiv

e Sc

reen

s

Pos. s

ent t

o Tre

atm

ent

0

1000

2000

3000

3117 2923

428123

Aug- Dec 2008

Aug Sep Oct Nov Dec0

0.51

1.52

2.53

3.54

4.55

1

5

4

2

0

2 2

1

0

4

2

3

0 0

2

Low IntermediateHigh

Suicide Risk Level

Jan Feb Mar Apr02468

1012141618

01

5

18

02

0

17

13

0

4

Low IntermediateHigh

Suicide Risk Level

Patie

nt Visits

Patie

nt Scr

eened

Positiv

e Sc

reen

s

Pos. s

ent t

o Tre

atm

ent

0

2000

4000

60006068

5346

706 279

Jan- Apr 2009

May June July0

5

10

15

20

25

30

15

24

15

2325

29

47

11

Low IntermediateHigh

Suicide Risk Level

Patie

nt Visits

Patie

nt Scr

eened

Positiv

e Sc

reen

s

Pos. s

ent t

o Tre

atm

ent

0

4000

8000

12000

1600015105 13622

1995580

May-July 2009

RESPECT-MILProgram Standards

Approach contained in “how to” manuals

Primary Care Providers undergo 2 hours of training

Routine primary care PTSD & Depression screening

Positive screens followed by diagnosis & severity assessment

Immediate Care-Facilitator assistance and accountable, continuous follow-up to remission

Weekly specialist input/supervision

BACH Performance

Each Provider has copies

> 95% of PCM have received initial training

> 95% of all routine visits in Carentan clinic receive screening

Average 14% of screens are positive for Depression and/or PTSD

93% of all patients referred to RESPECT- Mil were contacted by RCF Mrs. Robin Slone

97 staffings conducted on 57 patients. Result: 56% had recommended treatment changes

Adult Behavioral Health April 2009 Behavior Health Counselors and Tech’s were

placed in Soldier Health Services Clinics to partner with RESPECT Mil, providing an opportunity to have Soldiers Behavioral Health needs met in a Primary Care setting

All appointments sick call, walk-ins and routine - scheduled appointments are screened for Depression, PTSD and suicide via RESPECT Mil forms

Intermediate to Low Risk Soldiers are counseled and followed until remission, ETS, PCS or transferred to specialty care; WTU, TBI or Adult Behavioral Health

All High Risk Soldiers are referred to Adult Behavioral Health for treatment and follow up

16

Prevalence & Impact Currently 10% of the population is suffering from a

major depressive disorder.

10 % of men and 20% of women will suffer from a major depressive episode in their lifetimes.

As many as 70% of those individuals were undiagnosed and untreated prior to RESPECT Mil

17

Prevalence & ImpactDEPPRESSIVE DISORDER ranks as the

5th most common diagnosed disorder

in the primary care setting.

(Only after hypertension, well-child checks, diabetes mellitus, and routine general medical examinations.)

(Dartmouth-Northern New England Coop - Summer 2003 report)

18

Post-Deployment Health Consequences

Hoge et al, AJP 2007

2,863 Iraq War Veterans one-year post-deployment

0%

10%

20%

30%

40%

50%

60%

Limb Pain Back Pain ≥2 Sickcalls/ mo

≥2 Missedwork days

PTSDNO PTSDTwice as many

sick call visits!!

0%

10%

20%

30%

40%

50%

60%

Limb Pain Back Pain ≥2 Sickcalls/ mo

≥2 Missedwork days

PTSD

NO PTSD

19

Common Treatment Options Primary Care Providers

Behavioral Health Specialist

Service Members

RESPECT Mil Care Facilitators, RN

20

Usual Treatment OptionsAntidepressant medications

Self management plans

Referral for psychological counseling and/or RESPECT Mil Care Facilitation

Combinations of any or all of the above

21

RESPECT Mil

& Adult Behavioral

Health Within the Clinics at Fort Campbell, KY

22

The Prepared Practice

PCM

Recognition & diagnosis (screening tools)

Patient treatment selection & education

Initiation of treatment & referral to Care Facilitation/Management

Continuing treatment & treatment modifications

Continuation/maintenance phase & relapse prevention

Pri

mary

Care

Pro

vid

ers

23

Care Facilitator = Registered Nurse

Serve as a guide not therapist

Facilitate adherence to treatment

Assess & monitor treatment response

Educates Soldiers about medication, Sleep Hygiene

Reassesses for PTSD, Depression and Suicide each contact

Schedules Counseling Appt. if warranted or referred

Communicates with PCM & Behavior Health Specialist

Coord

inate

s

Com

mu

nic

ati

on

Care Facilitation

24

The Behavioral Health Interface

Consulting Psychiatrist and Counselor

Care Facilitator Case Staffing

Informal consultation with clinicians

Formal patient consultation & treatment

Psychological assessment & counseling recommendations

Beh

avi

ora

l H

ealt

h

Sp

eci

ali

st

25

Support StaffRESPECT Mil Medical Support Staff

Assist with screening & use of screening tools

Use of depression/PTSD management forms & recordkeeping

Communication protocols

Calculate statistics for each clinic

Scheduling and linkages with Care Facilitators

Su

pp

ort

Sta

ff

PATIENT VISITS

26459

PATIENTS SCREENED

23977

90.6%

POSITIVE SCREENS 4056

16.9%

General Statistics ( March 08- July 09)

Patient Visits Patients Screened

Positive Screens

0

5000

10000

15000

20000

25000

30000

Patients Seen at Clinic

% of total

positive screens

POSITIVE SCREENS 3973

POSITIVE FOR DEPRESSION 1337 33%

POSITIVE FOR PTSD 448 11%

POSITIVE FOR PTSD&DEPRESSION 1168 29%

FALSE POSITIVE 1020 26%

Positi

ve S

cree

ns

Positi

ve- D

epre

ssio

n

Positi

ve-P

tsd

Pisitiv

e Dep

ress

ion-

Ptsd

False

Pos

itive

0500

1000150020002500300035004000

3973

1337

448

1168 1020

Positive Diagnosis

POSITIVE SCREENS MINUS FALSE POSITIVES 2953

POSITIVE SCREENS ALREADY IN RESPECT MIL 122

POSITIVE SCREENS ALREADY IN ABH 1128

POSITIVE SCREENS ALREADY IN TREATMENT (RM, ABH, OTHER)

1321

Positi

ve m

inus

Fal

se P

ositi

ve

Positi

ve a

lread

y in

Res

pect

-Mil

Positi

ve a

lread

y in

ABH

Positi

ve a

lread

y in

trea

tmen

t0

500

1000

1500

2000

2500

3000

2953

122

1128 1321

Positive Already in TX

REFERRED TO R.M. 462

REFERRED TO ABH. 325

REFERRED TO OTHER SOURCE 119

VISITS REFERRED (RM, ABH, BOTH, OTHER)

1113

Referred to Re-

spect-Mil

Referred to ABH

Referred to other source

Visits referred

0

200

400

600

800

1000

1200

462325

119

1113Referrals

Advantages of RESPECT Mil ProgramAdditional Resources (education, “tools”

and additional Staff)Improved screening/identification Diagnostic tools add objectivity to treatment

planImproved Suicidal Risk AssessmentImproved Communication between Primary

Care and Specialty Care through RCFFacilitates a Primary Care “team approach”

Advantages of Behavioral Health in Clinics

Additional ResourcesImmediate evaluation for positive risk

for suicideDecreased escorts via command Direct admit to inpatient statusImproved counseling appointments keptDecreased stigma of Adult Behavioral

Health

Challenges at Fort CampbellProviders and staff see RESPECT-Mil as extra workSupervision of RCFs and AAs (HN or Champion)Contacting Soldiers by telephone during duty hoursProviders understanding that RCFs do not counselFollow-up Soldiers that are Inpatient, PCS, ETSDuplication of work (paper & electronic charting)Whether to screen every visitPCP diagnosis PTSDDividing caseload for RCFs

QUESTIONS