Sample Reference for Health Care Assistant

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					  Desk Reference Toolbox for
Post-Deployment Health Clinical
      Practice Guideline
                           14 Jul 10
 Presentation Outline

 History of the Post-Deployment Health Clinical
  Practice Guideline (PDH-CPG)
 Original PDH-CPG Tool Kit
 Change from Tool Kit to Toolbox
 Contents of Toolbox
 Updates to Toolbox
  Clinical Practice Guideline for
  Post-Deployment Health

 DoD/VA Post-Deployment Health Evaluation and
  Management Clinical Practice Guideline (PDH-CPG)
   • Evidence-based guideline for the evaluation and management
     of patients with deployment-related health concerns/conditions
     in the primary care setting
   • Completed by an expert multi-disciplinary, multi-agency panel
   • Replaced Comprehensive Clinical Evaluation Program (CCEP)
   • Initiated with a worldwide satellite broadcast January 2002 and
     distribution of Tool Kits to all MTFs
   • No change since 2002 except new Toolboxes distributed to
     MTFs starting in July 2004 and coding guidance modified
PDH-CPG Use Mandated by
Health Affairs – April 2002

“All DoD military treatment facilities should now be using
the Post-Deployment Health Clinical Practice Guideline
…the military unique vital sign question ‘Is the reason for
your visit today related to a deployment?’ should be asked of
every patient … providers will review and employ, as
needed, this guideline during their evaluations…”
 Overview of PDH-CPG

                             Primary Care Clinic Visit
 Post-Deployment Health     Military Vital Sign Screening      Post-Deployment Health
Assessment – DD Form 2796                                   Reassessment – DD Form 2900

                                  Symptomatic With
                                    No Diagnosis
     Asymptomatic                                                  Symptomatic With
      Concerned         Medically Unexplained Symptoms                Diagnosis
     Algorithm A1                   Algorithm A2                     Algorithm A3

   V65.5 and V70.5_6            799.89 and V70.5_6          Disease Code and V70.5_6

Culture Change Strategy for the
PDH-CPG Rollout Jan 02

 Guideline Implementation Champion and Team
  were to be set up at each MTF
 Clinician and Patient Education – encouraging
  patient’s active role in care
 Creation and use of Tools
 Web site and Tool Kit created to support the
  adoption and use of the PDH-CPG
 Worldwide Web Support for
 Post-Deployment Health Care
 Audience
   • Clinicians, service members, veterans and families
   • All services, all compos
Content Areas
   • Deployment support
   • PDH and other deployment-related CPGs
   • Health conditions and concerns
   • Healthcare and support services
   • Education and training
   • Risk communication
   • Deployment-related research
   • News and forms library
Types of Material
   • Policies and directives                 • Relevant research and news
   • Clinical guidance                       • Forms and measures
   • Provider/patient education material     • Related links
PDH-CPG Web-Based Tools

 PDH Guidelines
   •   Overview
   •   Guideline
   •   Algorithms
   •   Implementation
   •   Desk Reference Toolbox
   •   Tool Kit (Updated by Toolbox)
   •   Broadcast, 30 Jan 2002
   •   Supporting Guidelines
        – Major Depressive Disorder
        – Medically Unexplained Symptoms
        – Post Traumatic Stress Disorder
Background for Creating Clinical
Practice Guideline “Tool Kits”

 Strategy for supporting changes in practice
   • Tools can relieve barriers to change
   • Periodic review of tools allow changes in system process
   • Tools provide systematic method for measuring progress
     in improving processes and outcomes of care
 Centrally produced and evaluated products can be
  replicated throughout all MTFs
   • Prevents the need to “reinvent the wheel” at each MTF
   • Standardization is easier for patients and staff who move
     to different facilities within DoD
 Presentation Outline

 History of the Post-Deployment Health Clinical
  Practice Guideline (PDH-CPG)
 Original PDH-CPG Tool Kit
 Change from Tool Kit to Toolbox
 Contents of Toolbox
 Updates to Toolbox
 Original 2002 PDH-CPG Tool Kit

 Large, heavy 23” x 12” x 11”
  canvas satchel containing:
   • 2.5” Three-ring binder
       – Narrative CPG with
       – Sample/description of
         each tool and support
   • 8.5” x 11” Provider
     Reference Cards
   • Documentation form (DD
     2844)                       Contents available on
   • Clinic stamps               Order some parts on
   • Reference book(s)
   • List of related web sites    Distributed 1 per 50 providers to every
   • Patient informational         military medical treatment facility in
     brochures                     January 2002
   • Patient marketing tools
 PDH Screening Question
 Marketing Tools in 2002 Tool Kit

To facilitate asking the Deployment-Related Question,
 posters and wallet cards can be placed in
 Primary Care Clinics


     Wallet Card

  Available from the Army MEDCOM QMO Web site:
(In Shopping Cart under Post-Deployment Health CPG ToolKit)
 Presentation Outline

 History of the Post-Deployment Health Clinical
  Practice Guideline (PDH-CPG)
 Original PDH-CPG Tool Kit
 Change from Tool Kit to Toolbox
 Contents of Toolbox
 Updates to Toolbox
 Lessons Learned from 2002

 Challenges with distribution of the Tool Kits
 Tool Kit too big, complex
 Culture change initiative not completely effective
 National Quality Management Program (NQMP)
  evidence showed that not all MTFs, not all Primary
  Care Providers were using the PDH-CPG
Redesign of Tool Kit to Toolbox

 Small portable tools – Toolbox sized to fit on
 Pocket-sized, laminated Reference Cards 5” x 7”
 Ease-of-access
   • Color-coding
   • Index readily available – in Toolbox lid
 Tools not intended as textbooks, but as reminders
   • Concise information
   • Targeted to role of Primary Care Provider
 PDH-CPG Desk Reference Toolbox

 Desktop-Sized Laminated Box
   • Desk Reference Cards
   • Compact Discs
       – Interactive PDH-CPG
       – MEDCOM CD of Other CPGs
       – 2 PDH-CPG Training CDs
   • Sample Clinician and Patient
   • Vaccine Healthcare Center’s
     Immunization Tool Kit

                                      Contents on
                                Distributed 1 per primary care provider
                                 in every military medical treatment facility
                                 starting July 2004
   Toolbox Web Page

Table of Contents
 Introduction
 Satisfaction Survey
 Ordering Information
 Provider Reference
   Pocket Cards
 Compact Discs (CDs)
 Brochures
 Related Links
(New/updated cards are
 developed and posted as
 Presentation Outline

 History of the Post-Deployment Health Clinical
  Practice Guideline (PDH-CPG)
 Original PDH-CPG Tool Kit
 Change from Tool Kit to Toolbox
 Contents of Toolbox
 Updates to Toolbox
Overview of Toolbox Table of

 Contact Information and Resources: Quick and easy
  access to phone and electronic information sources
 PDH Guideline Elements: PDH-CPG algorithms and clinic visit
 Specific Medical Conditions and Concerns: Summary
  information on managing a variety of deployment-related health
  concerns e.g., Depleted Uranium
 Risk Communication: Methods to integrate health risk
  communication into a deployment-related healthcare encounter
 Screening and Outcome Measures: Primers for forms used
  during deployment-related healthcare visits e.g., DD Form 2796
 Training: A brief summary of currently available PDH-CPG
  education and training materials
 Process Improvement and Metrics: A summary of metrics used
  in deployment-related healthcare
Toolbox Table of Contents
Toolbox Reference Cards
DHCC Contact Information and
 Deployment Health Clinical Center
 A DoD Center of Excellence

 Clinical Services
   • Specialized Care Program – Tracks I and II
                                                     DHCC Experience
   • Clinician and Service Member Helplines
   • Worldwide Ambulatory Referral Program
 Outreach and Education
   •   Email Deployment Health News
   •   Deployment-Related Education Material
   •   Staff Training and Assistance Team
   •   Annual Force Health Protection Conference
 Health Services Research
                                        Proponent for VA/DoD Post-
   • Clinical, Epidemiological and
                                         Deployment Health Clinical
     Health Services                     Practice Guideline
   • Web-Based Treatment
 DHCC Clinical Care
 Specialized Care Program
 (SCP Tracks I and II)

 Intensive, 3-week, multidisciplinary, outpatient
  rehabilitative program for patients with deployment-related
  chronic illness or Medically Unexplained Symptoms or post
  traumatic stress and trauma spectrum symptoms
 Available to all military members and family members who
  continue to have problems after going through PDH-CPG based
  care at local MTF and meet admission criteria (e.g., ambulatory,
  capable of some exercise) (Track II for military members only)
 Behavioral and self-care strategies and treatments include
     •   Physical conditioning    •   Occupational therapy
     •   Patient education        •   Relaxation training
     •   Counseling               •   Cognitive-behavioral therapy
     •   Nutritional counseling   •   Exposure therapy
Toolbox Table of Contents
PDH-CPG Algorithms

                         Toolbox Reference Cards

 Interactive Guideline
 Toolbox Reference Cards
 PDH-CPG Provider Reference Card
 Key Elements

 Provides synopsis of PDH-CPG
  Key Elements
   • Identify if health concerns
     are deployment-related
   • Triage patients and seek to
     reach a working diagnosis
   • Manage asymptomatic patients
     with health concerns
   • Manage patients with established
   • Manage patients with unexplained
 Toolbox Reference Cards
 PDH Clinic Visit

 Provides guidance for
  training screeners about the
  deployment-related question
   • How to ask the question
   • Emphasizes that deployment
     is not necessary to have PDH
   • How to respond to patients’
   • Examples of deployments and
     deployment-related concerns or
 PDH Visit Coding - Replaced
 Desk Reference Card

Revised May 2005
Replaced by fact sheet based
  on Military Health System
  Coding Guidance: Professional
  Services and Coding Guidelines
  Version 3.0
  Unified Biostatistical Utility, 2008
Deployment-Related Visit Coding -
Replaced PDH Visit Coding Card

 Revised November 2009
 Based on Military Health
  System Coding Guidance:
  Professional Services and
  Coding Guidelines
  Unified Biostatistical Utility
Toolbox Table of Contents
Toolbox Reference Cards



    Chemical Agents
Toolbox Reference Cards
Associated Guidelines

              Medically Unexplained

                   Major Depressive Disorder

                            Suicide

                                            PTSD
                                           (in Toolboxes
                                           starting Jan 05)
Toolbox Reference Card
Vaccine Healthcare Centers
Emerging Health Concerns (EHC)
Resources on

 Reference sources
   • Tri-Service policies and directives
   • Related internet links
 Provider information
   •   Clinical guidance
   •   Fact sheets
   •   Forms and measures
   •   Educational material
   •   Research information
 Patient information
   • Fact sheets
   • Educational material                  Depleted Uranium Card
Toolbox Table of Contents
 Toolbox Reference Cards
 Risk Communication

 Definition
 Factors in gaining
  trust and credibility
 ENVITE mnemonic
Toolbox Table of Contents
 Deployment Health Assessment
 Forms and Primers
                                          DD Form 2795
 DD Form 2795, Pre-Deployment                             DD 2795 Primer
  Health Assessment, May 99
   • Reviewed by a credentialed
     provider for positive responses                                        DD Form 2796
   • Primer in Toolbox and on Web
                                                           DD 2796 Primer
 DD Form 2796, Post-Deployment
  Health Assessment, Jan 08 and
 DD Form 2900, Post-Deployment             DD Form 2900

  Health Reassessment, Jan 08
   • Face to face assessment by trained                          DD 2900 Primer
     health care provider (physician,
     physician assistant, nurse practitioner,
     independent duty corpsman/medical
   • Updated Primers on Web
                                 Available on
  Enhanced PDHA Process

 Guidance for Completing
  DD Form 2796
 PDHA Policies & Directives
 Deployment Exposures
 Redeployment Briefing
 PDHA Training Videos

                         Available on
                                          Toolbox DD2796 Primer
  PDHRA Process Resources

 Clinical Guidance
 PDHRA Policies & Directives
 Information for Concerns
  Related to
   • Deployment Exposures
   • Medical
   • Behavioral Health
 Healthcare Resources
 PDHRA Training Material

                             Available on
  Toolbox DD2900 Primer
DD Form 2844 - Post Deployment
Medical Assessment Form and
                             DD Form 2844
 Optional form
 Used in place of SF 600
  for documenting post-
  deployment evaluation
 Can be completed on line

DD 2844 Primer
 Post Traumatic Stress Disorder
 Checklists, Primer and PTSD-CPG

 Post Traumatic Stress Disorder
  Checklists (PCL)
   • Assesses trauma-related distress
   • Self-administered
 VA/DoD Clinical Practice Guideline
  for Management of Post Traumatic
  Stress Disorder (PTSD-CPG)
   • Released Jan 04 – No Tool Kit
   • 5 Modules, including Primary Care

                                                       Available on
  Additional Assessment and
  Outcome Tools

 PHQ - Patient Health
   • Screens and monitors status
     of common health conditions
 PDCAT - Post Deployment                 PDCAT
  Health Clinical Assessment Tool
   • Measures certain aspects of
     physical and mental health
   • Useful in following post-
     deployment health conditions

  Forms and primers on
Toolbox Table of Contents
Toolbox Table of Contents
 Implementation Metrics

 Chart Audit
   • Documentation that beneficiary was asked if their visit
     was deployment-related
   • If visit was deployment-related, was (Optional) DD Form
     2844 used?
   • If visit was deployment-related, was a specialty referral
     made? (Provider’s discretion)
 Electronic Records Review
   • Ambulatory encounters for post-
     deployment concern were coded with
     ICD-9 code (V70.5_6) in ADM
 Provider Survey
4 Compact Discs (CDs) of
Reference and Training Resources

 Stand-alone copy of the PDH-CPG Interactive
 PDH-CPG Training Briefs
 Deployment Health Clinical Training Series
 MEDCOM CD containing Clinical Practice and Disease
  Management Guidelines
 (Updated CD Version available from MEDCOM QMO Web
  PDH-CPG Training Briefs

 Produced by DHCC Jan 04
 7 video modules
  from 7-12 minutes
 Developed for
  medical providers
  and support staff
 CD in Toolbox and
  posted on DHCC                       Table of Contents
  Web site               Introduction               Health Risk Communication
                         Primary Care Screening     Coding and Documentation       Primary Care Evaluation PDHA
                         Management & Follow-up
  Deployment Health Clinical
  Training Series

 Produced by DHCC Jan 04
 11 modules from
  17-47 minutes
 Video, script, slides
 Developed for medical
  providers and support                Table of Contents
  staff                    PDH-CPG                  Emerging Health Concerns
                              • Introduction/Overview   • Suicide
 CD in Toolbox and           • Screening/Evaluation    • Malaria
  posted on DHCC Web          • Management/Follow-up    • Depleted Uranium
                              • Risk Communication      • Leishmaniasis
  site       • Coding/Documentation    • Vaccine Safety
                              • PDHA Process
 Presentation Outline

 History of the Post-Deployment Health Clinical
  Practice Guideline (PDH-CPG)
 Original PDH-CPG Tool Kit
 Change from Tool Kit to Toolbox
 Contents of Toolbox
 Updates to Toolbox
New/Revised Desk Reference Cards

 PTSD Card
   • Six-sided card on Post Traumatic Stress Disorder (PTSD)
     created in Sep 04 and included in Toolboxes distributed since Jan 05
 PDHRA Primer Card, January 2008
   • Two-sided card on DD Form 2900, Post-Deployment Health
      Reassessment (PDHRA) created and posted on Web Feb 08
 PDHA Primer Card, January 2008
   •   Update of original PDHA Primer to coincide with the update of
        the DD Form 2796 and posted on Web Feb 08
 Depleted Uranium Card
   • Update of original DU Card. Posted on Web Feb 10
 Deployment-Related Visit Coding Card
   • Update of original PDH Coding Card with revised coding guidance.
        Posted on Web Feb 10
New/Revised Desk Reference Cards

 Major Depressive Disorder (MDD) Guideline Card
   • Update of original MDD Card to coincide with revised VA/DoD
      MDD Clinical Practice Guideline. Posted on Web Feb 10
 Specialized Care Program (SCP) Card
   • Update of original SCP Card with more detailed information on SCP
     Track I and Track II. Posted on Web Feb 10
 DHCC Contact Information Card
   • Update of original DHCC Contact Information Card with revised
     email and mailing addresses. Posted on Web Feb 10
 Pre-Deployment Health Assessment Primer Card
   • Update of original Pre-Deployment HA Primer Card for DD Form 2795.
     Posted on Web Jul 10

 Available on Toolbox Page on
Additional Deployment Health
Clinical Training Series Presentations

 Medically Unexplained
  Symptoms (MUS) Clinical
  Practice Guideline, Jan 06
 Major Depressive Disorder
  (MDD) Clinical Practice
  Guideline, May 07
 Video, script, slides
 Developed for medical
 Available on

 In summary, the PDH-CPG Toolbox should:
  • Help Primary Care Providers treat patients with
    deployment-related health concerns
  • Promote PDH-CPG integration in MTFs
  • Minimize frustration for patients who present
    with difficult-to-diagnose deployment-related
    health concerns
Questions, Information,

DoD Deployment Health Clinical Center     202-782-6563
Walter Reed Army Medical Center                DSN:662
Building T2
6900 Georgia Ave, NW                    Provider Helpline
Washington, DC 20307-5001               1-866-559-1627

E-mail:         Patient Helpline
Website:               1-800-796-9699

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