Headquarters U S Air Force Integrity Service Excellence

Headquarters U. S. Air Force Integrity - Service - Excellence USAF Post-Deployment Health Reassessment Program James W. Haynes, Lt Col, USAF, MC Chief Consultant, Family Medicine Services Office of the Surgeon General 1

Overview n What is PDHRA? n How did it develop? n What We Kind of Know n Moving Toward DX n Lessons Learned n Where Are We Going? UNCLASSIFIED Integrity - Service - Excellence 2

What is PDHRA? Post-deployment Health Reassessment (DD Form 2900) n OSD/Ha-mandated 10 March 2005 n Standardized Assessment Instrument n Completed 90 -180 Days After A Return From Deployment n Includes 16 Questions n Both Physical And Behavioral Health Questions n n Healthcare Provider Evaluation (For Positives Only In The Air Force) UNCLASSIFIED Integrity - Service - Excellence 3

Why ? n n n Reports Deployment-related Health Concerns That Emerge Over Time Enhances Force Health Protection And Readiness Program; Extends Deploymentrelated Healthcare Provides A Population Level Health Assessment For Early Identification And Intervention Demonstrates Caring Posture To Those Who Serve Through Targeted Outreach Procedures Removes Barriers To Care, De-stigmatize Care-seeking At All Levels …. An Opportunity To Engage Unaddressed Health Care Needs… UNCLASSIFIED Integrity - Service - Excellence 4

Timeline ? AF/SGO Memo Beta-Test PDHRA at Team Web App Formed Developed Seymour User’s Johnson Guide and Kx Site Developed OCT 2005 UNCLASSIFIED NOV DEC JAN AF/CVA Memo AF/SGO Memo for Contract Hires UDM Roster Site Created FEB MAR APR Over 39, 056 PDHRAs Completed! MAY JAN 07 2006 Integrity - Service - Excellence 5

ADAF Member Returns from Deployment PHSD UM Role: Contact UDM and at 120 & 150 day mark if PDHRA is not yet completed UDM Notifies Member to Complete PDHRA DD Form 2900 at 90 days Is the Member on PRP? YES NO PHSD UM Role: * Member Completes PDHRA in Clinic Member Completes PDHRA Online *PCE Completes Page 4 of the DD Form 2900 Electronically in PIMR for Positives Is PDHRA Positive NO Check to see if PDHRA is reviewed within a duty day; Check to see if Page 4 is completed NLT 30 days YES PDHRA Monitor Contacts Member’s PCE and Sends PDHRA Results MTF Places PDHRA DD Form 2900 in the Member’s Medical Record * The MTF will use their standard of care to evaluate and treat PDHRA positive members. UNCLASSIFIED *PCE Completes Page 4 of the PDHRA DD Form 2900 Electronically in PIMR END Integrity - Service - Excellence 6

Additional Question Sets n Alcohol Use Disorders Identification Test (AUDIT) 10 -item Screening Questionnaire n A Score Of 8 Or More Is Associated With Harmful Or Hazardous Drinking n A Score Of 13 Or More In Women, And 15 Or More In Men, Is Likely To Indicate Alcohol Dependence n n Post Traumatic Stress Disorder (PTSD) Checklist-military Version (PCL-M) n n Standardized Self-report Rating Scale For PTSD Comprising 17 Items That Correspond To The Key Symptoms Of PTSD Modified Patient Health Questionnaire (PHQ-9) n Brief 9 -item Patient Self-report Depression Assessment With Question 9 About Suicidal Ideation Removed From The Webapplication UNCLASSIFIED Integrity - Service - Excellence 7

PDHRA Completion Rate For Current ADAF As Of 26 Jan 07 50, 984 Total 77% * Excludes members who have separated or retired UNCLASSIFIED Integrity - Service - Excellence 8

Screener: Percent ADAF Positive Total = 42, 492 NOT POSITIVE 24, 490 (58%) POSITIVE 18, 002 (42%) UNCLASSIFIED Integrity - Service - Excellence 9

Page 4 Compliance Metric: ADAF Compliance Overall: Total Positive Overall 18, 002 Page 4 ACCOMPLISHED PERCENT 15, 393 85. 5% Compliance Within 30 Days: # DAYS TO ACCOMPLISH UNCLASSIFIED Page 4 ACCOMPLISHED PERCENT 0 -30 10, 920 70. 9% >30 4, 473 29. 1% Integrity - Service - Excellence 10

Types of Positives: ADAF PHYSICAL & MENTAL 6, 972 (38. 7%) PHYSICAL ONLY 7, 254 (40. 3%) MENTAL ONLY 3, 776 (21%) Total = 18, 002 UNCLASSIFIED Integrity - Service - Excellence 11

Screener Symptom Type*: ADAF TYPE OF CONCERN NUMBER PERCENT OF POSITIVES PERCENT OF TOTAL PDHRAs Physical symptoms 4, 145 22. 97% 9. 2% Exposure 1, 411 7. 82% 3. 1% Depression symptoms 1, 305 7. 23% 2. 9% PTSD symptoms 585 3. 24% 1. 3% Anger/aggression 245 1. 36% 0. 5% Suicidal ideation 104 0. 58% 0. 2% Social/family conflict 773 4. 28% 1. 7% Alcohol use 247 1. 37% 0. 6% Other 224 1. 24% 0. 5% None 12140 67. 28% 27% *Multiple Responses Possible UNCLASSIFIED Integrity - Service - Excellence 12

Moving Toward A Diagnosis n Included in analysis if 4 conditions were met: Arrived in theater ≥ July 1 st, 2004 n Departed from theater ≤ Mar 31 st 2006 n Were ADAF 6 months prior to deployment and 6 months after n Had no other deployment 12 months prior and 6 months after n Active Duty 6 Months 01 -Jan-04 6 Months 01 -Jul-04 DEPLOYMENT PERIOD 31 -Mar-06 30 -Sep-06 41, 712 met the criteria n All outpatient diagnoses are included (not just primary) n UNCLASSIFIED Integrity - Service - Excellence 13

ICD-9 -CM Appendix E Groupings n n n n Infectious and parasitic Neoplasms Endocrine, Nutritional, Metabolic, Immune Blood Mental Health* Nervous/Sense Circulatory Respiratory n n n n n * Mental Digestive Genitourinary Pregnancy/Childbirth Skin/Subcutaneous Musculoskeletal/Connective Congenital Perinatal Ill-Defined Injury/Poisoning Uncovered Using Comprehensive Behavioral Health ICD-9 Groupings (CBHIG) UNCLASSIFIED Integrity - Service - Excellence 14

Overview of Results: ICD-9 -CM Groupings Most Prevalent Post-Deployment Groupings Musculoskeletal / Connective Nervous / Sensory Respiratory Ill-Defined Injury / Poisoning Skin / Subcutaneous UNCLASSIFIED Integrity - Service - Excellence 15

Musculoskeletal / Connective AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total Negative 26, 639 (63. 9%) 6, 607 (15. 8%) 33, 246 (79. 7%) Positive 4, 681 (11. 2%) 3, 785 (9. 1%) 8, 466 (20. 3%) 31, 320 (75. 1%) 10, 392 (24. 9%) 41, 712 (100%) Total UNCLASSIFIED Integrity - Service - Excellence 16

Nervous / Sensory AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total Negative 24, 053 (58. 7%) 6, 948 (16. 7%) 31, 451 (75. 4%) Positive 6, 838 (16. 4%) 3, 423 (8. 2%) 10, 261 (24. 6%) 31, 341 (75. 1%) 10, 372 (24. 9%) 41, 712 (100%) Total UNCLASSIFIED Integrity - Service - Excellence 17

Respiratory AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total Negative 27, 943 (67. 0%) 5, 654 (13. 5%) 33, 597 (80. 5%) Positive 5, 335 (12. 8%) 2, 780 (6. 7%) 8, 115 (19. 5%) 33, 278 (79. 8%) 8, 434 (20. 2%) 41, 712 (100%) Total UNCLASSIFIED Integrity - Service - Excellence 18

Ill-Defined AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total Negative 28, 806 (69. 1%) 5, 963 (14. 3%) 34, 769 (83. 4%) Positive 4, 617 (11. 1%) 2, 326 (5. 6%) 6, 943 (16. 6%) 33, 423 (80. 1%) 8, 289 (19. 9%) 41, 712 (100%) Total UNCLASSIFIED Integrity - Service - Excellence 19

Injury / Poisoning AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total Negative 29, 406 (70. 5%) 5, 510 (13. 2%) 34, 916 (83. 7%) Positive 5, 040 (12. 1%) 1, 756 (4. 2%) 6, 796 (16. 3%) 34, 446 (82. 6%) 7, 266 (17. 4%) 41, 712 (100%) Total UNCLASSIFIED Integrity - Service - Excellence 20

Skin / Subcutaneous AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 33, 401 (80. 1%) 3, 692 (8. 8%) 37, 093 (88. 9%) 3, 357 (8. 1%) 1, 262 (3. 0%) 4, 619 (11. 1%) 36, 758 (88. 2%) 4, 954 (11. 8%) 41, 712 (100%) Integrity - Service - Excellence 21

Comprehensive Behavioral Health ICD-9 CM Groupings (CBHIG) n n n n Infectious and parasitic Neoplasms Endocrine, Nutritional, Metabolic, Immune Blood Mental Health Nervous/Sense Circulatory Respiratory Digestive Genitourinary Pregnancy/Childbirth Skin/Subcutaneous Musculoskeletal/Connective Congenital UNCLASSIFIED n n n Perinatal Ill-Defined Injury/Poisoning V 1 -9 Communicable V 10 -19 Personal/family history V 20 -29 Reproductive/development services V 30 -39 Liveborn infants V 40 -49 Condition influencing health V 50 -59 Procedure/aftercare services V 60 -69 Services Other circumstances V 70 -85 Exam-No diagnosis Insert list of groups Integrity - Service - Excellence 22

Overall Mental Health AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 36, 019 (86. 4%) 2, 923 (7. 0%) 38, 942 (93. 4%) 1, 845 (4. 4%) 925 (2. 2%) 2, 770 (6. 6%) 37, 864 (90. 8%) 3, 848 (9. 2%) 41, 712 (100%) Integrity - Service - Excellence 23

Overview of Results: CBHIG Most Prevalent Post-Deployment Mental Groupings Tobacco Depression Anxiety Adjustment Alcohol Dx Deferred / NK UNCLASSIFIED Integrity - Service - Excellence 24

Tobacco AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 39, 665 (95. 1%) 1, 160 (2. 8%) 40, 825 (97. 9%) 668 (1. 6%) 219 (0. 5%) 887 (2. 1%) 40, 333 (96. 7%) 1, 379 (3. 3%) 41, 712 (100%) Integrity - Service - Excellence 25

Depression AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 40, 250 (96. 5%) 727 (1. 7%) 40, 977 (98. 2%) 512 (1. 2%) 223 (0. 5%) 735 (1. 8%) 40, 762 (97. 7%) 950 (2. 3%) 41, 712 (100%) Integrity - Service - Excellence 26

Anxiety AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total 40, 592 (97. 3%) 655 (1. 6%) 41, 247 (98. 9%) 349 (0. 8%) 116 (0. 3%) 465 (1. 1%) 40, 941 (98. 2%) 771 (1. 9%) 41, 712 (100%) Includes PTSD UNCLASSIFIED Integrity - Service - Excellence 27

Adjustment AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED Negative Positive Total 41, 141 (98. 6) 358 (0. 9%) 41, 499 (99. 5%) 193 (0. 5%) 20 (0. 1%) 213 (0. 5%) 41, 334 (99. 1%) 378 (0. 9%) 41, 712 (100%) Integrity - Service - Excellence 28

Alcohol AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 41, 136 (98. 6%) 272 (0. 7%) 41, 410 (99. 3%) 250 (0. 6%) 52 (0. 1%) 302 (0. 7%) 41, 388 (99. 2%) 324 (0. 8%) 41, 712 (100%) Integrity - Service - Excellence 29

Dx Deferred / NK AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 41, 350 (99. 1%) 255 (0. 5%) 41, 575 (99. 7%) 126 (0. 3%) 11 (0. 03%) 137 (0. 3%) 41, 476 (99. 4%) 236 (0. 6%) 41, 712 (100%) Integrity - Service - Excellence 30

PTSD: ICD-9 -CM = 309. 81 AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 41, 556 (99. 6%) 139 (0. 3%) 41, 695 (99. 96%) 12 (0. 03%) 5 (0. 01%) 17 (0. 04%) 41, 568 (99. 65%) 144 (0. 35%) 41, 712 (100%) Integrity - Service - Excellence 31

Screener: ADAF Enlisted Endorsing ≥ 3 PTSD Symptoms AFSC N of positives N ( ≥ 3 PTSD ) % Transportation vehicle maintenance 569 36 6. 3 Medics 293 20 6. 8 Security forces 654 34 5. . 2 Mission support 102 6 5. 9 Info management & computer systems 376 12 3. 2 Civil engineering 709 18 2. 5 Enlisted-other 542 18 3. 3 Communication electrical systems 230 11 4. 8 Manned aerospace maintenance 1105 29 2. 6 Fuels 162 2 1. 2 Munitions & weapons 232 5 2. 2 Intelligence 115 5 4. 3 Services 173 4 2. 3 Air crew operations 229 4 1. 7 Air crew protection 45 2 4. 4 Command control/System Operations 184 3 1. 6 Missile maintenance 8 0 0 Public affairs 19 0 0 5747 209 3. 6 All UNCLASSIFIED Integrity - Service - Excellence 32

Screener: ADAF Officer Endorsing ≥ 3 PTSD Symptoms AFSC N of positives N ( ≥ 3 PTSD ) % Professional (Judge Advocate/Chaplain) 24 2 8. 3 Medical 147 13 8. 8 Support 162 3 1. 9 Acquisition & Finance 48 1 2. 1 Logistics 85 2 2. 4 Operations 411 7 1. 7 Officer-Other 17 0 0 All 894 28 3. 1 UNCLASSIFIED Integrity - Service - Excellence 33

V-Code Counseling: Overall AFTER DEPLOYMENT BEFORE DEPLOYMENT Negative Positive Total UNCLASSIFIED 39, 227 (94. 0%) 1, 224 (2. 9%) 40, 451 (97. 0%) 1, 080 (2. 6%) 181 (0. 4%) 1, 261 (3. 0%) 40, 307 (96. 6%) 1, 405 (3. 4%) 41, 712 (100%) Integrity - Service - Excellence 34

Study Takeaways n Utilization Of Mental Health Resources Increases Post Deployment n Prevalence Anxiety Disorders Doubles Post Deployment n Overall Anxiety Diagnoses Relatively Low n AF Focus: Total Continuum of Deployment-Related Mental Health Disorders UNCLASSIFIED Integrity - Service - Excellence 35

Lessons Learned Feedback From The Field Questionnaire Is Too Sensitive n Unit Level Deployment Monitor’s Difficult To Identify n Clinical Care Issues Positive PDHRA but Member Refuses Further Evaluation? n “Burden” On Thinly-stretched Fam Med/Flight Surgeon Shops n Can Direct Referrals Be Made To LSSC For BH + Only? n Answer What You Can Early… Someone Else Is Bound To Ask UNCLASSIFIED Integrity - Service - Excellence 36

Future n Caution - “Mission Drift”------ Are We Missing The Continuum? n Data Base Is Evolving --- Improvement In Collection/Analysis Process Based Measures (# Referrals, Types Of Referrals, Etc) n Outcomes Data (Dx, Tx Measures, Better Or Not? ) n n Moving Toward Diagnoses --- Targets For Prevention And Treatment n “Compliance” Standards For Contacting Members n Who Are The “Refusal To Take” Group? n Improve Total Force Continuum Of Care (ANG, AFRC, AD, VA) UNCLASSIFIED Integrity - Service - Excellence 37

Useful Links n n n PDHRA Form: https: //www. afchips. brooks. af. mil/phdra PHSD PDHRA Knowledge Junction: https: //kx. afms. mil/pdhra PDHealth PDHRA Page: http: //www. pdhealth. mil/dcs/pdhra. asp PDHRA Provider Training: http: //www. pdhealth. mil/dcs/Blue. Sky/index. html AMSA Status Report: https: //www. afchips. brooks. af. mil/PIMR/AMSA_Update. HTM Compliance Stats on AFCHIPs: https: //www. afchips. brooks. af. mil/main. htm UNCLASSIFIED Integrity - Service - Excellence 38

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BACKUP SLIDES UNCLASSIFIED Integrity - Service - Excellence 41

GWOT $$s Used to Fund Behavioral Health Consultants at 37 Bases n Anticipated/Sold With Expectation They May Be Able To Help With PDHRA Processing In Addition To Other Duties n Initial Plan: Hire Civilian For Life Skills Support Center (Lssc) To Allow Blue-suiter To Serve As BHC In The PCE And Facilitate PDHRA Process Along With Other Bhc Roles n Almost All 37 Bases Now Have Contracts In Place, And Money Obligated, With The Expectation That Hires Will Be In Place Late July/August UNCLASSIFIED Integrity - Service - Excellence 42

Air Force Bases with Most Deploying Personnel since 1 January 2003 Counts unique deployers* Location AD RG Total Charleston 1880 380 2260 Hurlburt Field 4556 48 4604 Spangdahlem 2214 0 2214 Robins 3220 439 3659 Incirlik 2200 0 2200 Pope 3510 21 3531 Lakenheath 2107 0 2107 Davis-Monthan 2811 564 3375 Hill 2057 18 2075 Seymour Johnson 2567 787 3354 Fairchild 1881 122 2003 Macdill** 3114 210 3324 Lackland 1827 131 1958 Travis 2705 474 3179 Barksdale 1411 530 1941 Eglin 2699 111 2810 Tinker 1806 127 1933 Nellis 2333 345 2678 Mcchord 1516 305 1821 Ramstein 2608 0 2608 Grandforks 1795 5 1800 Langley 2429 45 2474 Aviano 1785 0 1785 Offutt 2064 395 2459 Wright Patterson 968 804 1772 Little Rock 2120 322 2442 Dover 1287 429 1716 Shaw 2417 12 2429 Beale 1654 47 1701 Moody 2407 1 2408 Scott 1377 305 1682 Mc. Connell 2007 369 2376 Mountainhome 1506 44 1550 Mc. Guire 1985 324 2309 Elmendorf 1484 20 1504 Dyess 2083 182 2265 Andrews** 1208 190 1398 AD = Active Duty - RG = Reserve/Guard UNCLASSIFIED Integrity - Service - Excellence 43

Who was included in the sample for analyses? Original Total 139, 340 ANG/AFRC -36, 303 103, 037 Don’t Meet 4 Conditions - 61, 325 Sample Total 41, 712 UNCLASSIFIED Integrity - Service - Excellence 44

CBHIG: V-Codes Counseling UNCLASSIFIED Integrity - Service - Excellence 45