DOD Health Care
Mental Health and Traumatic Brain Injury Screening Efforts Implemented, but Consistent Pre-Deployment Medical Record Review Policies Needed Gao ID: GAO-08-615 May 30, 2008The John Warner National Defense Authorization Act for Fiscal Year 2007 included provisions regarding mental health concerns and traumatic brain injury (TBI). GAO addressed these issues as required by the Act. In this report GAO discusses (1) DOD efforts to implement pre-deployment mental health screening; (2) how post-deployment mental health referrals are tracked; and (3) screening requirements for mild TBI. GAO selected the Army, Marine Corps, and Army National Guard for the review. GAO reviewed documents and interviewed DOD officials and conducted site visits to three military installations where the pre-deployment health assessment was being conducted.
DOD has taken positive steps to implement mental health standards for deployment and pre-deployment mental health screening. However, DOD's policies for providers to review medical records are inconsistent. DOD issued minimum mental health standards that servicemembers must meet in order to be deployed to a combat theater and identified the pre-deployment health assessment as a mechanism for ensuring their use in making deployment decisions. DOD's November 2006 policy implementing these deployment standards requires a review of servicemember medical records during the pre-deployment health assessment. However, DOD's August 2006 Instruction on Deployment Health, which implements policy and prescribes procedures for conducting pre-deployment health assessments, is silent on whether such a review is required. Because of this inconsistency, providers determining if Operation Enduring Freedom and Operation Iraqi Freedom servicemembers meet DOD's mental health deployment standards may not have complete medical information. Health care providers at the installations GAO visited where the post-deployment health assessment (PDHA) is conducted manually track whether servicemembers who receive mental health referrals from the PDHA make or complete appointments with mental heath providers. Because health care providers conducting the PDHA and making referrals from the PDHA may not have an ongoing relationship with referred servicemembers, health care providers responsible for tracking referrals at these installations have developed manual systems to track servicemembers to ensure that they made or kept their appointments for evaluations. Tracking is more challenging for Guard and Reserve units because their servicemembers generally receive civilian care. Guard and Reserve units do not know if servicemembers used civilian care to complete their PDHA referrals unless disclosed by the servicemembers, which they may be reluctant to do because of stigma concerns. DOD is addressing the TBI requirement through implementing screening for mild TBI in its PDHA and prior to deployment. DOD has also provided guidance and training for health care providers. DOD in January 2008 added TBI screening to the PDHA, and plans to require screening of all servicemembers for mild TBI prior to deployment beginning in July 2008. The TBI screening questions on the PDHA assess the servicemember's exposure to events that may have increased the risk of a TBI and the servicemember's symptoms. The TBI screening questions to be used prior to deployment are similar to those on the PDHA. Prior to DOD's screening efforts, several installations had been screening servicemembers for mild TBI before or after deployment. An official from the Defense and Veterans Brain Injury Center told GAO that these initiatives would probably be replaced by the DOD-wide screening.
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Report to Congressional Addressees:
United States Government Accountability Office:
GAO:
May 2008:
DOD Health Care:
Mental Health and Traumatic Brain Injury Screening Efforts Implemented,
but Consistent Pre-Deployment Medical Record Review Policies Needed:
GAO-08-615:
GAO Highlights:
Highlights of GAO-08-615, a report to congressional addressees.
Why GAO Did This Study:
The John Warner National Defense Authorization Act for Fiscal Year 2007
included provisions regarding mental health concerns and traumatic
brain injury (TBI). GAO addressed these issues as required by the Act.
In this report GAO discusses (1) DOD efforts to implement pre-
deployment mental health screening; (2) how post-deployment mental
health referrals are tracked; and (3) screening requirements for mild
TBI. GAO selected the Army, Marine Corps, and Army National Guard for
the review. GAO reviewed documents and interviewed DOD officials and
conducted site visits to three military installations where the pre-
deployment health assessment was being conducted.
What GAO Found:
DOD has taken positive steps to implement mental health standards for
deployment and pre-deployment mental health screening. However, DOD‘s
policies for providers to review medical records are inconsistent. DOD
issued minimum mental health standards that servicemembers must meet in
order to be deployed to a combat theater and identified the pre-
deployment health assessment as a mechanism for ensuring their use in
making deployment decisions. DOD‘s November 2006 policy implementing
these deployment standards requires a review of servicemember medical
records during the pre-deployment health assessment. However, DOD‘s
August 2006 Instruction on Deployment Health, which implements policy
and prescribes procedures for conducting pre-deployment health
assessments, is silent on whether such a review is required. Because of
this inconsistency, providers determining if Operation Enduring Freedom
and Operation Iraqi Freedom servicemembers meet DOD‘s mental health
deployment standards may not have complete medical information.
Health care providers at the installations GAO visited where the post-
deployment health assessment (PDHA) is conducted manually track whether
servicemembers who receive mental health referrals from the PDHA make
or complete appointments with mental heath providers. Because health
care providers conducting the PDHA and making referrals from the PDHA
may not have an ongoing relationship with referred servicemembers,
health care providers responsible for tracking referrals at these
installations have developed manual systems to track servicemembers to
ensure that they made or kept their appointments for evaluations.
Tracking is more challenging for Guard and Reserve units because their
servicemembers generally receive civilian care. Guard and Reserve units
do not know if servicemembers used civilian care to complete their PDHA
referrals unless disclosed by the servicemembers, which they may be
reluctant to do because of stigma concerns.
DOD is addressing the TBI requirement through implementing screening
for mild TBI in its PDHA and prior to deployment. DOD has also provided
guidance and training for health care providers. DOD in January 2008
added TBI screening to the PDHA, and plans to require screening of all
servicemembers for mild TBI prior to deployment beginning in July 2008.
The TBI screening questions on the PDHA assess the servicemember‘s
exposure to events that may have increased the risk of a TBI and the
servicemember‘s symptoms. The TBI screening questions to be used prior
to deployment are similar to those on the PDHA. Prior to DOD‘s
screening efforts, several installations had been screening
servicemembers for mild TBI before or after deployment. An official
from the Defense and Veterans Brain Injury Center told GAO that these
initiatives would probably be replaced by the DOD-wide screening.
What GAO Recommends:
GAO is recommending that DOD address the inconsistency in its policies
by revising its Instruction on Deployment Health to require a review of
medical records as part of the pre-deployment health assessment. DOD
concurred with GAO‘s recommendation and said it will update its
Instruction to require a medical record review at the time of the pre-
deployment health assessment for servicemembers with a significant
change in health status since their most recent annual health
assessment. GAO believes that DOD‘s proposed action does not fully
address the recommendation, and DOD should require a medical record
review as part of the pre-deployment health assessment for all
servicemembers.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-615]. For more
information, contact Cynthia A. Bascetta at (202) 512-7114 or
bascettac@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
DOD Has Taken Steps to Implement Pre-Deployment Mental Health
Screening, but Policies for Medical Record Reviews Are Inconsistent:
Health Care Providers at Installations Visited Manually Track Mental
Health Referrals from the PDHA:
Health Care Providers Receive Mental Health Training and Guidance; DOD
and the Military Services Are Implementing New Training Initiatives:
DOD Is Implementing Mild TBI Screening for All Servicemembers and Has
Provided Guidance and Training for Health Care Providers:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: New Post-Deployment Health Assessment (DD 2796), January
2008:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Table:
Table 1: DOD Deployment-Cycle-Based and Annual Health Assessments:
Figures:
Figure 1: Pre-Deployment Health Assessment Questions (DD 2795):
Figure 2: TBI Screening Questions on the PDHA:
Abbreviations:
AHLTA: Armed Forces Health Longitudinal Technology Application:
ANAM: Automated Neuropsychological Assessment Metrics:
BTBIS: Brief Traumatic Brain Injury Screen:
CHCS: Composite Health Care System:
CPG: clinical practice guideline:
DOD: Department of Defense:
DSG: Deployment Support Group:
DVBIC: Defense and Veterans Brain Injury Center:
IDC: independent duty corpsman:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
MACE: Military Acute Concussion Evaluation:
MHAT: Mental Health Advisory Team:
MTF: military treatment facility:
NDAA: National Defense Authorization Act:
PDHA: post-deployment health assessment:
PDHRA: post-deployment health reassessment:
PHA: periodic health assessment:
PTSD: post-traumatic stress disorder:
TBI: traumatic brain injury:
VA: Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
May 30, 2008:
Congressional Addressees:
Since the initiation of military conflicts in Afghanistan--Operation
Enduring Freedom (OEF)--and Iraq--Operation Iraqi Freedom (OIF)--
servicemembers have engaged in intense and prolonged combat, placing
them at risk for developing post-traumatic stress disorder (PTSD) or
other mental health conditions. Those with PTSD often relive their
stressful experiences, such as exposure to combat, through nightmares
and flashbacks, and may have difficulty sleeping and feel detached or
estranged. A 2006 Army mental health advisory team report found that 20
percent and 15 percent of Army and Marine Corps OIF servicemembers,
respectively, screened positive for PTSD, depression, or anxiety.
[Footnote 1]
Servicemembers who have engaged in combat are also at risk for
experiencing a traumatic brain injury (TBI). TBI, which is a physical
injury rather than a mental health condition, has emerged as the
leading injury among OEF and OIF servicemembers. The nature of the
current conflicts--in particular the use of improvised explosive
devices--increases the likelihood that servicemembers will be exposed
to incidents such as blasts that can cause a TBI. Based on data from
2004 to 2006 at selected military installations, the Department of
Defense (DOD) estimates that about 10 to 20 percent of OEF/OIF Army and
Marine Corps servicemembers have sustained a mild TBI, commonly known
as a concussion.[Footnote 2]
DOD is required by law to have a system to assess the medical condition
of servicemembers before and after deployment to locations outside the
United States.[Footnote 3] The required elements of this system include
the use of pre-and post-deployment medical examinations. To implement
the system, DOD uses multiple health assessments to screen
servicemembers for a variety of health concerns, including mental
health concerns, both before and after their deployments to combat
theaters. These assessments include the pre-deployment health
assessment, the post-deployment health assessment (PDHA), and the post-
deployment health reassessment (PDHRA). During these assessments, a
servicemember completes a form that includes questions used to screen
for mental health concerns. A health care provider reviews the
completed form and may refer the servicemember for further evaluation
if necessary.
Questions have been raised about DOD's mental health screening of
servicemembers before and after their deployments to OEF/OIF.[Footnote
4] In 2007 a DOD Mental Health Task Force reported that DOD faced
several challenges to effective mental health assessments, including
eagerness to deploy or stigma, that may prevent servicemembers from
disclosing mental health concerns on the pre-deployment health
assessment or the PDHA respectively, and recommended that DOD
coordinate the mental health screening questions that are used on the
health assessment forms to ensure accuracy and consistency.[Footnote 5]
In May 2006 we reported that DOD could not provide reasonable assurance
that OEF/OIF servicemembers who need referrals for mental health
following deployments receive them.[Footnote 6]
There has also been interest in ensuring that servicemembers are
screened for TBI, particularly mild TBI.[Footnote 7] Mild TBI can be
difficult to identify in part because, unlike with more severe forms of
TBI, there may be no observable head trauma and because some of its
symptoms overlap with other conditions, such as PTSD.[Footnote 8] In
May 2007 an Army TBI Task Force report identified gaps in TBI screening
efforts across all levels of Army health care, such as few military
installations that had been conducting TBI screening before deployment
and a lack of policies requiring TBI screening after
deployment.[Footnote 9]
The John Warner National Defense Authorization Act for Fiscal Year 2007
(NDAA), enacted on October 17, 2006, included a provision that
addressed DOD's efforts to screen servicemembers for mental health
concerns and TBI.[Footnote 10] In particular, the Act required DOD to:
* issue minimum mental health standards that servicemembers must meet
in order to be deployed and take actions to ensure their utilization;
* use the pre-deployment health assessment and PDHA to screen
servicemembers for treatment and medication use for a mental health
condition;
* as part of its deployment health quality assurance program, document
the effectiveness of DOD tracking mechanisms used to ensure that
servicemembers who are referred for mental health evaluations from the
PDHA receive them;
* document the mental health training received by health care providers
conducting the PDHA, as well as develop guidance for these health care
providers to use in deciding whether to refer a servicemember for a
mental health evaluation; and:
* screen servicemembers for TBI in the pre-and post-deployment health
assessments, develop guidance, and ensure health care providers
conducting the assessments receive training on TBI.
Furthermore, the 2007 NDAA required us to report on DOD's
implementation of this provision, and 11 members of Congress also
expressed interest in this work. In this report we discuss (1) DOD
efforts to implement 2007 NDAA requirements related to mental health
screening in the pre-deployment health assessment, including issuing
mental health standards for deployment; (2) how mental health referrals
made as a result of the PDHA are tracked to ensure that referred
servicemembers receive evaluations; (3) the training and guidance on
mental health issues received by health care providers conducting the
PDHA; and (4) DOD efforts to implement 2007 NDAA requirements for TBI
screening, including the guidance and training DOD makes available to
health care providers for identifying mild TBI.
We reviewed DOD efforts involving active duty and reserve components of
the Army and Marine Corps; we also included the Army National Guard in
our review. As of September 2007, these components comprised about 88
percent of all OEF/OIF forces. Although Air Force and Navy personnel
serve in OEF/OIF, Army and Marine Corps servicemembers generally serve
in ground combat roles, and servicemembers involved in combat are more
at risk for exposure to events that can lead to mental health
conditions and physical injuries such as TBI. Our findings related to
mental health and TBI screening that are military service-and component-
specific cannot be generalized across other military services or across
DOD.
To discuss DOD efforts to implement 2007 NDAA requirements related to
mental health screening in the pre-deployment health assessment,
including issuing mental health standards for deployment, we reviewed
federal laws, DOD and military service-specific policies and guidance
related to deployment health, deployment standards, and the pre-
deployment health assessment. We conducted three site visits to
military installations--one Army unit at Fort Campbell, Kentucky; one
Marine Corps unit at Camp Lejeune, North Carolina; and one Army
National Guard unit at Fort Richardson, Alaska. We selected these
installations based on their deployment schedules in order to observe
the pre-deployment screening process.[Footnote 11] During these site
visits, we interviewed commanders about their role in making
determinations of whether a servicemember may deploy, and DOD health
care providers about their role in conducting the pre-deployment health
assessments.
To discuss how mental health referrals made as a result of the PDHA are
tracked to ensure that referred servicemembers receive evaluations, we
defined tracking as the process in which a health care provider or
other official monitors whether an individual servicemember referred
from the PDHA makes or completes his or her appointment for a mental
health evaluation. We reviewed DOD and military service-specific
policies and guidance related to the PDHA. We interviewed DOD and
military service officials about the types of electronic and manual
systems that can be used to track referrals from the PDHA, and health
care providers at Fort Campbell and Camp Lejeune about the electronic
and manual systems that they use to track these referrals.[Footnote 12]
To discuss the training and guidance on mental health issues received
by health care providers conducting the PDHA, we reviewed DOD and Army,
Navy, and Marine Corps health care provider education and training.
[Footnote 13] We reviewed DOD clinical practice guidelines (CPG)
[Footnote 14] related to mental health conditions associated with
deployment, and other guidance related to the PDHA with respect to
mental health issues. We also interviewed DOD and military service
officials regarding these issues. We interviewed 4 health care
supervisors and 15 physicians and independent duty corpsmen (IDC) at
Fort Campbell and Camp Lejeune who were available during our visit
about their training and qualifications related to mental health.
Finally, we observed health care provider training at Fort Bragg, North
Carolina for an Army program that trains primary care providers in
identifying and treating servicemembers with depression and PTSD.
To discuss DOD efforts to implement 2007 NDAA requirements for TBI
screening, including the guidance and training DOD makes available to
health care providers for identifying mild TBI, we reviewed DOD
policies and guidance, and military service-specific policies and
guidance, including the January 2008 final report of the Army TBI Task
Force. We also interviewed DOD and military service officials,
including officials from the Defense and Veterans Brain Injury Center
(DVBIC),[Footnote 15] on installation-specific processes used to screen
servicemembers for mild TBI prior to or following deployment as well as
DVBIC's training programs for health care providers. We discuss DOD's
screening with respect to mild TBI rather than moderate to severe TBI
because in general, mild TBI can be more difficult to identify than
moderate to severe TBI. We conducted our work from July 2007 through
May 2008 in accordance with generally accepted government auditing
standards.
Results in Brief:
DOD has taken steps to implement mental health standards for deployment
and screen servicemembers for mental health conditions prior to
deployment, but policies for providers to review medical records are
inconsistent. To meet the requirements related to deployment mental
health standards and screening, DOD issued a November 2006 policy to
establish and implement minimum mental health standards for deployment.
The policy identified the pre-deployment health assessment as a
mechanism for screening servicemembers for mental health conditions and
for ensuring that the standards are utilized in making deployment
determinations. The policy also required a review of servicemember
medical records as part of this assessment. Such a review serves to
validate information servicemembers disclose about their mental health.
However, DOD's August 2006 Instruction on Deployment Health (DoDI
6490.03), which implements policy and prescribes procedures for
deployment health activities, is silent on whether a review of medical
records is required as part of the pre-deployment health assessment.
During our site visits to three installations, we found that health
care providers were unaware that a medical record review was required,
and medical records were not always reviewed by providers conducting
the pre-deployment health assessment. Because of DOD's inconsistent
policies, providers determining if OEF and OIF servicemembers meet
DOD's minimum mental health standards for deployment may not have
complete medical information.
Health care providers at Fort Campbell and Camp Lejeune manually track
PDHA mental health referrals to ensure that referred servicemembers
make or complete their appointments for evaluations. For example, at
Fort Campbell, mental health referrals from the PDHA are tracked by a
health care provider using a database she created and updates manually
with information from a DOD electronic system used to make referrals.
At Camp Lejeune, servicemembers' PDHA referrals to the division
psychiatrist are tracked by providers using hard-copy log books. A Fort
Campbell health care provider we spoke with said that health care
providers who make referrals from the PDHA may not have an ongoing
relationship with the servicemembers they refer and, therefore, manual
systems have been created to track whether referred servicemembers make
their evaluations. In addition, some Reserve members' mental health
referrals from the PDHA are manually tracked. However, referral
tracking is difficult for Guard and Reserve units because their
servicemembers generally receive care from civilian providers, which
they do not have to disclose, and because servicemembers may be
reluctant to disclose mental health encounters to military providers
due to stigma concerns.
Health care providers who conduct the PDHA receive training in mental
health issues that varies by the provider type, and DOD and the
military services are implementing mental health training initiatives;
furthermore, DOD offers guidance to health care providers on making
mental health assessments. According to health care providers at two
installations we visited, physicians, physician assistants, or IDCs
generally conduct the PDHA. These health care providers receive varying
levels of training on mental health issues, based on provider type,
during their basic medical education. For example, physicians receive
mental health training in medical school, while IDCs receive training
in psychiatric disorders as part of a unit that covers several types of
medical conditions. DOD also provides CPGs and other guidance for
health care providers on conducting mental health assessments.
Familiarity with these CPGs varied among health care providers we spoke
with, and some providers were comfortable with making mental health
assessments, while others were less comfortable in conducting the
assessments. The military services have implemented training
initiatives for health care providers; for example, the Army has
implemented a program that trains primary care providers in identifying
PTSD and depression. In addition, DOD plans to develop and distribute a
core curriculum for health care providers on mental health issues.
In response to the 2007 NDAA requirement for pre-and post-deployment
TBI screening, guidance and training DOD has added screening questions
for TBI to the PDHA, plans to require screening servicemembers for mild
TBI prior to deployment, and has provided guidance and training to
health care providers. In January 2008 DOD added TBI screening
questions to the PDHA. The questions are in four series that assess the
servicemember's exposure to events that may have increased the risk of
a TBI and symptoms of a TBI the servicemember may have. DOD is also
planning to require screening of all servicemembers for mild TBI prior
to deployment beginning in July 2008. The screening questions to be
used prior to deployment are similar to the screening questions on the
PDHA, and are included in a cognitive assessment tool that will provide
a baseline of cognitive function in areas such as memory and reaction
time. Prior to DOD's efforts, several installations had been screening
servicemembers for mild TBI before or after deployment. A DVBIC
official told us that these initiatives probably would be replaced by
the DOD-wide screening. In October 2007, DOD issued guidance for
identifying mild TBI for providers screening, assessing, and treating
servicemembers outside the combat theater, and DOD and the military
services have trained health care providers on identifying possible
mild TBI.
In order to address the inconsistency in DOD's policies related to the
review of medical record information and to assure that health care
providers have reviewed the medical record when screening
servicemembers prior to deployment, we recommend that the Secretary of
Defense direct the Under Secretary of Defense for Personnel and
Readiness to revise the DOD Instruction on Deployment Health to require
a review of medical records as part of the pre-deployment health
assessment. In commenting on a draft of this report, DOD concurred with
our recommendation. DOD said it will update its Instruction on
Deployment Health to require a medical record review at the time of the
pre-deployment health assessment for any servicemembers who have a
significant change in health status since their most recent periodic
health assessment, which is a health assessment administered to all
servicemembers annually. However, it is unclear how the health care
provider conducting the pre-deployment health assessment will identify
those with significant changes in health status. We believe that DOD's
proposed action does not fully address our recommendation, and DOD
should require a medical record review for all servicemembers as part
of the pre-deployment health assessment in its updated Instruction in
order to eliminate the inconsistency between its policy and the current
Instruction on Deployment Health. DOD also provided technical comments,
which we incorporated as appropriate.
Background:
Substantial numbers of ground combat Army and Marine Corps
servicemembers are exposed to combat experiences often associated with
an increased risk of developing PTSD or other mental health conditions.
Specifically, according to a 2004 study, more than half of Army or
Marine Corps ground combat units in OEF or OIF report being shot at or
receiving small-arms fire, seeing dead or seriously wounded Americans,
or seeing ill or injured women or children who they were unable to
help. More than half of Marine Corps servicemembers and almost half of
Army servicemembers reported killing an enemy combatant in OIF.
[Footnote 16] In addition to certain types of experiences, multiple
deployments are also associated with mental health problems. For
example, a 2006 Army mental health advisory team report found that Army
servicemembers who had been deployed more than once were more likely to
screen positive for PTSD, depression, or anxiety than those deployed
only once.[Footnote 17] In a 2008 Army mental health advisory team
report, 27 percent of Army male non-commissioned officers in their
third or fourth deployment screened positive for PTSD, depression, or
anxiety (compared to 12 percent of those on their first deployment).
[Footnote 18]
Servicemembers are also exposed to events such as blasts that increase
their risk of experiencing a TBI. TBI occurs when a sudden trauma
causes damage to the brain and can result in loss of consciousness,
confusion, dizziness, trouble with concentration or memory, and
seizures. Of particular concern are the after-effects of a mild TBI
that may not have resulted in readily apparent symptoms at the time of
the injury.[Footnote 19] A recent study found that mild TBI was
associated with high combat intensity and multiple exposures to
explosions in combat.[Footnote 20] Identification of mild TBI is
important, as treatment has been shown to mitigate the injury's
effects, which can include difficulty returning to work or completing
routine daily activities. DVBIC has issued a screening tool called the
Military Acute Concussion Evaluation (MACE), which is based on a
screening tool widely used in sports medicine and is intended to
evaluate a servicemember within 48 hours of the suspected injury. In
June 2007, the Army required health care providers to document a
servicemember's blast exposure in theater using the MACE. DVBIC also
issued in December 2006 a CPG for the management of mild TBI in
theater.[Footnote 21] The guidance contains a structured series of
questions that include certain "red flags," such as worsening headaches
or slurred speech, that should trigger further evaluation for a
possible mild TBI. Treatments for mild TBI may include education,
medication, and physical and psychiatric therapy.[Footnote 22]
Deployment Cycles and DOD Health Assessments:
There are multiple opportunities during the deployment cycle for
screening and assessing servicemembers' health status. Specifically,
DOD requires three health assessments during the deployment cycle: the
pre-deployment health assessment, the PDHA, and the PDHRA. In addition,
DOD requires an annual periodic health assessment (PHA). These
assessments and their associated forms are described in Table 1.
Table 1: DOD Deployment-Cycle-Based and Annual Health Assessments:
Name and Form (if applicable): Pre-deployment health assessment; (DD
2795);
Purpose and description:
* To record general information about servicemembers' health for
surveillance purposes and identify any health concerns that may need to
be addressed prior to deployment;
* A health care provider is to review the DD 2795, which is completed
by the servicemember. If any concerns are identified that may affect
the servicemember's ability to deploy, the servicemember may be
referred for further evaluation;
* Initiated in 1998;
Timing: Within 60 days prior to deployment.
Name and Form (if applicable): Post-deployment health assessment
(PDHA); (DD 2796);
Purpose and description:
* To identify and refer servicemembers with health concerns as a result
of deployment;
* A health care provider is to review the DD 2796, which is completed
by the servicemember, and conduct an interview to discuss any
deployment-related health concerns with the servicemember and if
necessary refer him or her for further evaluation;
* Initiated in 1998;
Timing: Within 30 days before or 30 days after return from deployment.
Name and Form (if applicable): Post-deployment health reassessment
(PDHRA); (DD 2900);
Purpose and description:
* To focus on servicemembers' health concerns that emerge over time
after return from deployment;
* A health care provider is to review the completed DD 2900, which is
completed by the servicemember, and conduct an interview to discuss any
deployment-related health concerns with the servicemember and if
necessary refer him or her for further evaluation;
* Initiated in 2005;
Timing: Within 90 to 180 days after return from deployment.
Name and Form (if applicable): Periodic health assessment (PHA);
Purpose and description:
* To assess changes in servicemembers' health status, especially
changes that could affect ability to perform military duties;
* Assessment includes screening the servicemember for medical
conditions (including screening for tobacco use, alcohol abuse and
stress management), treatments, and medications; reviewing the medical
record; and if necessary referring the servicemember for treatment of
current health problems;
* Initiated in 2006;
Timing: Annually.
Source: DOD.
[End of table]
Pre-Deployment Health Assessment:
DOD's Instruction on Deployment Health[Footnote 23], which implements
policies and prescribes procedures for deployment health activities,
requires deploying servicemembers to complete the pre-deployment health
assessment form, the DD 2795, within 60 days prior to the expected
deployment date. The DD 2795 is a brief form for servicemembers to self-
report general health information in order to identify any health
concerns that may limit deployment or need to be addressed prior to
deployment, and consists of eight questions that each servicemember
must complete (see fig. 1).
Figure 1: Pre-Deployment Health Assessment Questions (DD 2795):
1. Would you say your health in general is:
Excellent;
Very good;
Good;
Fair;
Poor.
2. Do you have any medical or dental problems?
Yes;
No.
3. Are you currently on a profile, or light duty, or are you undergoing
a medical board?
Yes;
No.
4. Are you pregnant? [Females Only];
Don't know;
Yes;
No.
5. Do you have a 90-day supply of your prescription medication or birth
control?
N/A;
Yes;
No.
6. Do you have two pairs of prescription glasses (if worn) and any
other personal medical equipment?
N/A;
Yes;
No.
7. During the past year, have you sought counseling or care for your
mental health?
Yes;
No.
8. Do you currently have any questions or concerns about your health?;
Yes;
No.
Please list your concerns:
Source: DOD.
[End of figure]
DOD's Instruction on Deployment Health states that after the
servicemember completes the DD 2795, the form is to be reviewed by a
health care provider, who can be a nurse, medical technician, medic, or
corpsman. If the servicemember indicates a positive, or "yes," response
to any one of certain questions (2, 3, 4, 7, or 8) the servicemember is
to be referred for an interview by a trained health care provider such
as a physician, physician assistant, nurse practitioner, or advanced
practice nurse. The provider signs the form indicating whether the
individual is medically ready for deployment, and a copy of the DD 2795
is placed in the servicemember's deployment health record. The
deployment health record is a summary of the medical record that is to
accompany the servicemember into theater. According to DOD's
Instruction on Deployment Health, this record should also contain a
record of the servicemember's blood type, allergies, corrective lens
prescription, immunization record, and a summary sheet listing past and
current medical conditions, screening tests, and prescriptions.
Post-Deployment Health Assessment:
DOD's Instruction on Deployment Health requires servicemembers
returning from deployment to complete the post-deployment health
assessment form, the DD 2796, within 30 days of leaving a combat
theater or within 30 days of returning to home or a processing station.
The DD 2796 is a form for servicemembers to self-report health concerns
commonly associated with deployments. In January 2008, DOD released a
new version of the DD 2796 that contains screening questions related to
mental health, including questions used to screen for depression,
suicidal thoughts, and PTSD.[Footnote 24] The screening questions for
depression, suicidal thoughts, and alcohol abuse are more detailed on
the new form than on the previous version of the DD 2796 (See appendix
I for a copy of the new version of the DD 2796). The DD 2796 must be
reviewed, completed, and signed by a health care provider.[Footnote 25]
According to DOD's Instruction on Deployment Health, the health care
provider conducting the assessment must be a physician, physician
assistant, nurse practitioner, advanced practice nurse, independent
duty medical technician or IDC,[Footnote 26] or Special Forces medical
sergeant.
According to DOD's Instruction on Deployment Health, the health care
provider review is to take place in a face-to-face interview with the
servicemember. The health care provider is to review the completed DD
2796 to identify any responses that may indicate a need for further
medical evaluation. In addition, the new DD 2796 contains guidance
intended to assist a provider in determining whether to make a referral
for some mental health concerns. For example, the form prompts the
provider to conduct a risk assessment for suicide depending on the
servicemember's response to the suicide risk questions. Health care
providers use a section of the DD 2796 to indicate when a servicemember
needs a referral. The referral field specifies both the concern for
which the servicemember is being referred, such as depression or PTSD
symptoms, and the type of care or provider to whom the servicemember is
being referred, such as primary care, mental health, specialty care,
family support services, chaplains, or Military OneSource.[Footnote 27]
DOD requires that the DD 2796 be placed in the servicemember's medical
record.[Footnote 28]
Periodic Health Assessment:
DOD requires an annual health assessment, the PHA, for all
servicemembers. The PHA is designed to ensure servicemember medical
readiness through monitoring servicemember health status and helps DOD
provide preventive care, information, counseling, or treatment if
necessary. In February 2006, DOD required the military services to
begin administering the PHA, which includes servicemember self-
reporting of health status, conditions, treatments, and medications;
provider review of the medical record and identification of and
referral for any health issues. The PHA also includes efforts to
identify and manage preventive needs, occupational risk and exposure as
well as identifying and recommending a plan to manage risks. DOD
requires its providers to record the results of the PHA in
servicemembers' medical records. DOD has created an online tool to
capture self-reported information from the PHA. A draft of this form
contains several mental health questions, including PTSD and depression
screening questions that are similar to the current PTSD and depression
questions on the DD 2796.
DOD Electronic Medical Records Systems Used to Make PDHA Referrals:
While several DOD information systems contain servicemember medical
information, the Composite Health Care System (CHCS) I and the Armed
Forces Health Longitudinal Technology Application (AHLTA), formerly
known as CHCS II, are the two electronic medical records systems
generally used by DOD health care providers to make PDHA referrals.
[Footnote 29] Although the military services currently employ both
systems, there are several differences between the two. For example,
CHCS I is a localized system, meaning information contained within CHCS
I is only available to medical facilities on a particular military
installation; information is not available to military treatment
facilities (MTFs) on other installations. In contrast, information in
AHLTA is available to medical facilities at different installations and
to providers in theater. Another distinction is that CHCS I sends
health care providers an email alert when a servicemember they refer
makes, completes, or cancels an appointment. If servicemembers do not
make appointments within 30 days, their referral is terminated from
CHCS I and the health care provider is notified by email. AHLTA does
not have this capability. DOD has been expanding AHLTA's capabilities
and plans on replacing certain CHCS I functions, such as laboratory
tests, with AHLTA.
DOD Has Taken Steps to Implement Pre-Deployment Mental Health
Screening, but Policies for Medical Record Reviews Are Inconsistent:
DOD has taken steps to meet the 2007 NDAA requirements for pre-
deployment mental health standards and screening. As required by the
2007 NDAA,[Footnote 30] which was enacted in October 2006, DOD issued
minimum mental health standards that servicemembers must meet in order
to be deployed. In a policy issued in November 2006,[Footnote 31] DOD
identified mental health disorders that would preclude a
servicemember's deployment, including conditions such as bipolar
disorder. DOD's policy also identified psychotropic medications that
would limit or preclude deployment if used by servicemembers--including
antipsychotic or anticonvulsant medications used to control bipolar
symptoms and certain types of tranquilizers and stimulant
medications.[Footnote 32] In addition to identifying the mental health
conditions and medications that would preclude deployment, DOD's policy
specified the circumstances under which servicemembers with other
mental health conditions can be deployed. Specifically, according to
DOD's policy, when a servicemember has been diagnosed with a mental
health condition that does not preclude deployment, the servicemember
should be free of "significant" symptoms associated with this condition
for at least three months before he or she can be deployed. The policy
also states that in making a deployability assessment, health care
providers should consider the environmental and physical stresses of
the deployment and whether continued treatment will be available in
theater. Finally, the policy identified the pre-deployment health
assessment as a mechanism for screening servicemembers for mental
health conditions and for ensuring that the standards are utilized in
making deployment determinations.
The 2007 NDAA also required DOD to use the pre-deployment health
assessment to identify those who are under treatment or have taken
psychotropic medications for a mental health condition.[Footnote 33]
The pre-deployment health assessment form, the DD 2795, includes a
question asking servicemembers whether they have sought mental health
counseling or mental health care in the past year. In a July 2007
report to Congress, DOD cited the pre-deployment health assessment in
describing its implementation of the 2007 NDAA requirements for pre-
deployment screening.[Footnote 34] The report also identified a medical
record review as a component of the pre-deployment health assessment
process to help meet these mental health screening requirements.
According to a senior DOD official,[Footnote 35] because servicemembers
may be reluctant to disclose symptoms or treatment that may prevent
them from deploying, the provider review of the medical record should
be done to verify the self-reported information on the DD 2795.
While medical records are an important part in making deployment
determinations, DOD's deployment policies are not consistent with
respect to their review. DOD's November 2006 policy on minimum mental
health standards for deployment states that the pre-deployment health
assessment includes a medical record review as part of ensuring the
standards are utilized, and DOD officials confirmed that the policy
requires such a review. However, DOD's August 2006 Instruction on
Deployment Health, which implements policies and prescribes procedures
for deployment health activities, is silent on whether a review of
medical records is required as part of the pre-deployment health
assessment. This Instruction states only that the pre-deployment health
assessment form, DD 2795, must be completed by each deploying
servicemember and the responses reviewed by a health care provider. A
health care provider following DOD's Instruction may not conduct the
medical record review during the pre-deployment health assessment
required by DOD's policy on minimum mental health standards for
deployment. Because of DOD's inconsistent policies, providers
determining if OEF and OIF servicemembers meet DOD's minimum mental
health deployment standards may not have complete medical information.
During our site visits, we found that practices varied with respect to
pre-deployment mental health screening, and medical records were not
routinely reviewed at the time of the pre-deployment health assessment
by the provider reviewing the DD 2795. While a review of medical
records can serve to validate information reported by servicemembers,
the health care providers we spoke with during our site visits were
unaware that it was required as part of the pre-deployment health
assessment. At all three installations we visited, servicemembers
completed the DD 2795 form. At two of the three installations all
servicemembers were interviewed by a health care provider to review
their responses on the DD 2795 and discuss any additional health
concerns. At the third installation, providers interviewed
servicemembers if they indicated any concerns on the DD 2795. While the
deployment health record was available to providers at all three
installations,[Footnote 36] the medical record was routinely reviewed
by the provider at only one of the three installations during the pre-
deployment health assessment. At the other two installations, providers
told us the record was reviewed only if servicemembers identified
concerns on the DD 2795 or during the interview.
Health Care Providers at Installations Visited Manually Track Mental
Health Referrals from the PDHA:
Health care providers at Fort Campbell and Camp Lejeune[Footnote 37]
manually track whether servicemembers who receive mental heath
referrals from the PDHA make or keep appointments for evaluations with
mental health providers. DOD does not require that individual referrals
from the PDHA be tracked; however, DOD has a quality assurance program
that monitors the PDHA, including follow-up encounters.[Footnote 38] In
addition, because Guard and Reserve servicemembers generally receive
civilian care, which they do not have to disclose, and because
servicemembers may be reluctant to disclose mental health encounters
due to stigma concerns, Guard and Reserve referrals are difficult to
track.
Health Care Providers at Visited Installations Manually Track PDHA
Mental Health Referrals:
While DOD health care providers generally make PDHA referrals using one
of two DOD information technology systems, AHLTA or CHCS I, health care
providers at military installations we visited have developed different
manual systems to track whether referred servicemembers made or kept
appointments with mental health providers. DOD does not require these
referrals to be tracked. However, a Fort Campbell health care provider
we spoke with said that the health care providers who make referrals
from the PDHA may not have an ongoing relationship with the referred
servicemembers and, therefore, manual systems have been created to
track whether referred servicemembers completed their evaluations.
According to installation health care providers, manually tracking
referrals is labor-intensive and time-consuming, and necessary to
ensure that referred servicemembers receive their evaluations.
We found that health care providers at Fort Campbell and Camp Lejeune
have developed manual tracking systems to ensure that servicemembers
receive evaluations. At Fort Campbell, the installation's readiness
processing manager, who is the health care provider who tracks PDHA
referrals, created an Access database for this purpose. The manager
checks CHCS I, the information technology system Fort Campbell
healthcare providers use to make PDHA referrals, daily to obtain their
status. Then, this individual manually enters the status of each
referral into the Access database, which allows all PDHA referrals and
their status to be viewed in one list. Servicemembers who fail to make
or keep their appointments are contacted, and if a servicemember does
not respond after two follow-up attempts, the unit commander is
informed.
At Camp Lejeune, health care providers track division servicemembers'
PDHA mental health referrals to the division psychiatrist using hard-
copy logbooks. Because the division psychiatrist's clinic does not have
access to AHLTA or CHCS I, health care providers make referrals by
phoning the division psychiatrist and follow-up with the psychiatrist
every two weeks to track whether servicemembers kept their
appointments. Camp Lejeune officials told us that, unlike the division,
the air wing's and logistics group's PDHA mental health referral
tracking is facilitated by having greater access to AHLTA, which allows
providers to check the status of appointments scheduled at the MTF.
Some Reserves' PDHA Mental Health Referrals Are Manually Tracked:
We found that mental health PDHA referrals for Marine Reserve members
who complete the PDHA at Camp Lejeune are tracked manually. Officials
from the Marine Reserves' Deployment Support Group (DSG)[Footnote 39]
at Camp Lejeune inform the home units of Reserve member referrals and
track their status. According to a Fort Campbell health care provider,
Army Reserve members are not processed through Fort Campbell following
deployment and, therefore, do not complete the PDHA at this
installation.
According to Guard and Reserve officials, home units rely largely on
servicemembers to disclose whether they receive care from a mental
health provider. Tracking PDHA mental health referrals is challenging
for the Guard and Reserves because their members generally receive
civilian care. Military health care providers would be unaware of
civilian care unless disclosed by the Guard and Reserve member. In
addition, Military OneSource, which is operated by a vendor contracted
by DOD, guarantees that it will not release the identity of
servicemembers who receive counseling unless servicemembers are at risk
of harming themselves or others. As a result, PDHA mental health
referral tracking is challenging for Guard and Reserve units due to
their reliance on servicemembers to disclose mental health encounters
with civilian providers, which Guard and Reserve officials told us they
may be reluctant to do because of stigma concerns.
Health Care Providers Receive Mental Health Training and Guidance; DOD
and the Military Services Are Implementing New Training Initiatives:
While DOD policy allows several types of health care providers to
conduct the PDHA, health care providers at Fort Campbell and Camp
Lejeune told us that health care providers actually conducting the
assessments are generally physicians, physician assistants, or, in the
case of the Marine Corps, IDCs. According to installation health care
providers, most of the physicians conducting the assessments have
specialties in primary care, which includes the specialties of family
practice and internal medicine.
The health care providers conducting these health assessments receive
varying levels of training in mental health issues based on provider
type during their basic medical education.[Footnote 40] For example,
physician assistants complete a rotation in psychiatry and may elect an
additional psychiatry rotation, while IDCs receive training in
psychiatric disorders as part of a unit on medical diagnosis and
treatment that covers several types of medical conditions. Physicians
receive mental health training in medical school.[Footnote 41]
DOD provides several types of guidance for health care providers to
help them conduct mental health assessments and decide whether to make
referrals for further evaluation. DOD maintains a Web site[Footnote 42]
that contains CPGs and other guidance and training that can be accessed
by health care providers conducting the assessments. For example, DOD
provides a set of reference materials on the Web site that contains
information on and steps to assess servicemembers for PTSD and major
depressive disorder. According to DOD, hard copy versions of these
reference materials were distributed to MTFs beginning in July 2004,
and MTFs may order additional copies.
We found that health care providers conducting the PDHA had varying
familiarity with the CPGs and levels of comfort in conducting
assessments. For example, at Camp Lejeune, some of the physicians and
IDCs we interviewed about DOD's guidance were not familiar with the
CPGs for depression and PTSD. Some physicians and IDCs cited resource
constraints, in the form of limited access to computers and internet
connectivity, as barriers to accessing these CPGs posted on the Web
site. At Fort Campbell, a brigade surgeon we spoke to who supervises
providers conducting the PDHA said that these providers have varying
knowledge of the CPGs. He stated that the guidance is distributed to
email accounts that some health care providers may not check regularly.
In addition, health care providers varied in their level of comfort in
making mental health assessments. At Camp Lejeune, eight of the 15
physicians and IDCs we interviewed were comfortable making mental
health assessments, while the remaining seven were less comfortable
making these assessments and expressed interest in receiving more
training on making mental health assessments. At Fort Campbell, the
division mental health providers we spoke with stated that while
physician assistants, for example, could identify a servicemember with
mental health concerns, these providers were generally not comfortable
in assessing servicemembers for mental health issues.
DOD and the military services have implemented and are in the process
of implementing several new mental health training initiatives. DOD
created the Center of Excellence for Psychological Health and Traumatic
Brain Injury in November 2007 that will focus on research, education,
and training related to mental health. According to DOD, the Center
will develop and distribute a core mental health curriculum for health
care providers, as well as implement policies to direct training in the
curriculum across the services. DOD plans to begin training primary
care providers in July 2008. The Army has created a program, RESPECT-
MIL,[Footnote 43] that trains primary care providers in identifying and
treating servicemembers with depression and PTSD. By the end of 2008,
the Army plans to train providers at 15 installations. The Army also
directed all servicemembers, including health care providers, to
participate in a training program that includes information on PTSD by
October 18, 2007. The training focused on the causes and physical and
psychological effects of PTSD and provided information on how to seek
subsequent treatment for this condition. As of January 31, 2008, 93
percent of Army servicemembers had received the training. The Army also
requires commanders to include PTSD awareness and response training in
pre-and post-deployment briefings. The Marine Corps has a training
program for non-mental health providers, including those that conduct
the PDHA, that includes training on PTSD. This training began in
January 2008 and is scheduled to train 669 health care providers at 12
sites by August 2008. The Marine Corps also requires pre-and post-
deployment briefings on identifying and managing combat stress for all
Marine Corps servicemembers and unit leaders.
DOD Is Implementing Mild TBI Screening for All Servicemembers and Has
Provided Guidance and Training for Health Care Providers:
In response to the 2007 NDAA, DOD added TBI screening questions to the
PDHA in January 2008 and plans in July 2008 to begin screening all
servicemembers prior to deployment. Prior to these TBI screening
efforts required by DOD, several installations had already implemented
efforts to screen servicemembers before or after their deployments. To
help health care providers screen servicemembers for mild TBI and issue
referrals, DOD has issued guidance and provided various forms of
training.
DOD Is Implementing Mild TBI Screening in Its PDHA and Prior to
Deployment; Several Installation-Specific Mild TBI Screening
Initiatives Are in Place:
In response to the 2007 NDAA requirement for pre-and post-deployment
screening for TBI, DOD has added TBI screening questions to the PDHA,
and plans to require screening of all servicemembers beginning in July
2008 for mild TBI prior to deployment. These screening questions are
similar to the screening questions on the PDHA. The questions are
included in a cognitive assessment tool that will provide a baseline of
cognitive function in areas such as memory and reaction time. In
January 2008, DOD released a new version of the post-deployment health
assessment form, the DD 2796, that contains screening questions for TBI
(See appendix I for a copy of the new version of the DD 2796).[Footnote
44]
The TBI screening questions added to the PDHA are designed to be
completed by the servicemember in four series.[Footnote 45] The
sequence of questions specifically assesses (a) events that may have
increased the risk of a TBI, (b) immediate symptoms following the
event, (c) new or worsening symptoms following the event, and (d)
current symptoms. (See appendix I.) If there is a positive response to
any question in the first series, the servicemember completes the
second and third series; if there is a positive response to any
question in the third series, the servicemember completes the fourth
series about current symptoms. The DD 2796 directs the health care
provider to refer the servicemember based on the servicemember's
current symptoms.[Footnote 46] See figure 2 for a description of these
screening questions.
Figure 7: TBI Screening Questions on the PDHA:
[See PDF for image]
This figure is an illustration of TBI Screening Questions on the PDHA.
The following information is depicted:
TBI Screening Tool:
Series 1: During this deployment, did you experience any of the
following events? (mark all that apply):
* Blast or Explosion;
* Vehicular accident/crash (including aircraft);
* Fragment wound or bullet wound above shoulders;
* Fall;
* Other event.
If positive response in the first series:
TBI Screening Tool Series 2:
Did you have any of the following happen to you immediately afterwards?
(mark all that apply):
* Losing consciousness/’knocked out“;
* Felt dazed, confused or ’saw stars“;
* Didn‘t remember the event;
* Concussion;
* Head injury.
Series 2 and 3 are both completed:
TBI Screening Tool Series 3:
Did any of the following problems begin or get worse afterwards? (mark
all that apply):
* Memory problems or lapses;
* Balance problems or dizziness;
* Sensitivity to bright light;
* Irritability;
* Headaches;
* Sleep problems;
* Ringing in ears.
If positive response in series three:
TBI Screening Tool Series 4:
In the past week, have you had any of the symptoms you indicated in
Series 3? (mark all that apply):
* Memory problems or lapses;
* Balance problems or dizziness;
* Sensitivity to bright light;
* Irritability;
* Headaches;
* Sleep problems;
* Ringing in ears.
The health care provider is to refer the servicemember based on
responses to Series 4.
Source: GAO analysis of DOD screening questions.
Note: See appendix I for complete questions.
[End of figure]
DOD is planning to require screening of all servicemembers for mild TBI
prior to deployment using questions similar to those on the PDHA. This
screening is planned to begin in July 2008 and these screening
questions are included in a cognitive assessment, the Automated
Neuropsychological Assessment Metrics (ANAM).[Footnote 47] The ANAM
will provide a baseline assessment of cognitive function in areas such
as memory and reaction time, which may be affected by a mild TBI.
[Footnote 48] If a servicemember experiences an event in theater, the
ANAM can be administered again and the differences in function
assessed. Because the ANAM does not distinguish between impairments in
cognitive function caused by events such as blasts and those caused by
other factors such as fatigue, the ANAM needs to be used with screening
questions to identify the event that may have caused a TBI. However,
the ANAM can be used to identify changes in baseline cognitive function
that may warrant further evaluation. According to an Army official,
since August 2007 about 50,000 Army servicemembers have been assessed
using the ANAM.
Prior to DOD's plans to screen all servicemembers on the PDHA and prior
to deployment, several installations had implemented, as early as 2000,
initiatives for mild TBI screening to be used before or after units
from those locations deployed. Generally, servicemembers participating
in these initiatives are screened using a three-question screen
developed by the DVBIC called the Brief Traumatic Brain Injury Screen
(BTBIS).[Footnote 49] The BTBIS is designed to identify servicemembers
who may have had a mild TBI, and includes questions about events and
symptoms that are similar to those used on DOD's PDHA. The first of
these initiatives began at Fort Bragg, North Carolina in 2000. Since
then, Fort Carson, Colorado; Fort Irwin, California; Fort McCoy,
Wisconsin and Camp Pendleton, California have initiated screening for
mild TBI either pre-deployment, post-deployment, or both.[Footnote 50]
A DVBIC official told us that these initiatives would probably be
replaced by the DOD-wide screening.
DOD Has Issued Guidance on Identification of Mild TBI and Trained Some
Health Care Providers on Identifying Mild TBI:
DOD issued guidance for health care providers on the identification of
mild TBI, trained some health care providers on identifying mild TBI,
and plans additional health care provider training initiatives. In
October 2007 DOD released guidance on identifying mild TBI for
providers screening, assessing, and treating servicemembers outside the
combat theater.[Footnote 51] The guidance contains information to help
health care providers conducting the PDHA, including follow-up
questions that the provider can ask a servicemember based on the
servicemember's responses to the TBI screening questions on the PDHA.
The guidance contains structured series of questions that include
certain "red flags," such as double vision or confusion, that suggest a
need for referral for further evaluation for a possible mild TBI. The
guidance recommends assessments and treatments for servicemembers with
symptoms such as irritability and includes screening tools to help
health care providers assess the severity of these symptoms. According
to a DOD official, DOD also plans to provide the military services with
guidance on using the new TBI screening questions on the PDHA.
In addition to issuing guidance, DOD and the military services also
trained health care providers on identifying possible mild TBI. In
September 2007 DOD held a tri-service conference in which more than 800
health care providers were trained. According to DVBIC officials, DVBIC
staff provide training through workshops for health care providers at
its 14 sites and travel to other installations to train health care
providers. In addition, DOD's planned Defense Center of Excellence for
Psychological Health and Traumatic Brain Injury, which began initial
operations on November 30, 2007, and is expected to be fully functional
by October 2009, will develop a national collaborative network to
advance and disseminate TBI knowledge, enhance clinical and management
approaches, and facilitate services for those dealing with TBI,
according to DOD. According to Army officials, the Army is also
initiating several health care provider training efforts for the summer
of 2008 designed to train primary care providers on mild TBI. According
to these officials, primary care providers are generally uncomfortable
with treating mild TBI, preferring instead to refer these cases to
specialty care. The Marine Corps' training program for non-mental
health care providers, including those conducting the PDHA, also
includes material on diagnosing mild TBI. With respect to the ANAM,
DVBIC officials told us that wherever this assessment tool is used,
DVBIC officials and officials responsible for the implementation of the
ANAM train health care providers in its use.
Conclusions:
DOD has taken positive steps to implement provisions of the 2007 NDAA
related to screening servicemembers for TBI and mental health. For
example, DOD has added mild TBI screening to its PDHA and will require
screening prior to deployment. With respect to mental health, we found
that health care providers' familiarity with DOD's CPGs and comfort in
making mental health assessments varied. However, DOD and the military
services have implemented or are implementing training initiatives,
some of which are specifically aimed at the primary care providers who
generally conduct the PDHA. Furthermore, the installations we visited
had developed manual systems for tracking those servicemembers who were
referred from the PDHA to ensure that they made or completed their
appointments. Referral tracking is difficult for the Guard and Reserves
because their servicemembers generally receive civilian care.
DOD has taken steps to meet 2007 NDAA requirements related to mental
health standards and screening, including issuing a policy on minimum
mental health standards for deployment. A key component of DOD's
efforts to meet these requirements is a review of medical records, and
we agree that this should be done to verify information in a screening
process that depends on self-reported information. Unfortunately, DOD's
policies for reviewing medical records during the pre-deployment health
assessment are inconsistent. During our site visits we found that
health care providers were unaware a medical record review was required
and that medical records were not always reviewed by providers
conducting the pre-deployment health assessment. A health care provider
following DOD's Instruction on Deployment Health, which is silent on
whether medical record review is required during the pre-deployment
health assessment, may not conduct the medical record review required
by DOD's policy on minimum mental health standards for deployment.
Until DOD resolves the inconsistency between its policies, its health
care providers may not have complete mental health information when
screening servicemembers prior to deployment.
Recommendation for Executive Action:
In order to address the inconsistency in DOD's policies related to the
review of medical record information and to assure that health care
providers have reviewed the medical record when screening
servicemembers prior to deployment, we recommend that the Secretary of
Defense direct the Under Secretary of Defense for Personnel and
Readiness to revise DOD's Instruction on Deployment Health to require a
review of medical records as part of the pre-deployment health
assessment.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, DOD stated that our concerns
regarding provider review of medical records are well-taken and that an
assessment is only complete when it includes a medical record review.
While DOD concurred with our recommendation and said that it will
update its Instruction on Deployment Health to require a medical record
review at the time of the pre-deployment health assessment, DOD is
limiting this medical record review requirement to servicemembers who
have a significant change in health status since their most recent
periodic health assessment. According to a senior DOD health official,
it is anticipated that the updated Instruction will be published in one
year. However, DOD does not explain how providers will be able to
identify the subset of servicemembers who have had a significant change
in health status. As a result, its response does not fully eliminate
the inconsistency between its policy and current Instruction. To fully
eliminate the inconsistency, as we recommended, DOD should require a
medical record review for all servicemembers as part of the pre-
deployment health assessment in its updated Instruction. We also
encourage DOD to update its Instruction as quickly as possible so that
providers have the complete information that we and DOD agree they need
to make pre-deployment decisions. DOD also provided technical comments,
which we incorporated as appropriate.
We are sending copies of this report to the Secretary of Defense; the
Secretaries of the Army, the Air Force, and the Navy; the Commandant of
the Marine Corps; and appropriate congressional committees and
addressees. We will also provide copies to others upon request. In
addition, the report is available at no charge on the GAO Web site at
[hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix III.
Signed by:
Cynthia A. Bascetta:
Director, Health Care:
List of Congressional Addressees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable Duncan L. Hunter:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Daniel K. Akaka:
United States Senate:
The Honorable Wayne Allard:
United States Senate:
The Honorable Christopher S. Bond:
United States Senate:
The Honorable Barbara Boxer:
United States Senate:
The Honorable Tom Harkin:
United States Senate:
The Honorable Joseph I. Lieberman:
United States Senate:
The Honorable Claire C. McCaskill:
United States Senate:
The Honorable Patty Murray:
United States Senate:
The Honorable Barack Obama:
United States Senate:
The Honorable Ken Salazar:
United States Senate:
The Honorable Bernard Sanders:
United States Senate:
[End of section]
Appendix I: New Post-Deployment Health Assessment (DD 2796), January
2008:
This form must be completed electronically. Handwritten forms will not
be accepted.
Post-Deployment Health Assessment (PDHA):
Privacy Act Statement:
Authority: 10 U.SC 136, 1074f, 3013, 5013, 8013 and E.O. 9397.
Principal Purpose(s): To assess your state of health after deployment
in support of military operations and to assist military healthcare
providers in identifying and providing present and future medical care
you may need. The information you provide may result in a referral for
additional healthcare that may include medical, dental or behavioral
healthcare or diverse community support services.
Routine Use(s): In addition to those disclosures generally permitted
under 5 U.S.C 552a (b) of the Privacy Act, to other Federal and State
agencies and civilian healthcare providers, as necessary, in order to
provide necessary medical care and treatment. Responses may be used to
guide possible referrals.
Disclosure: Voluntary. If not provided, healthcare will be furnished,
but comprehensive care may not be possible.
Instructions: Please read each question completely and carefully before
entering your response or marking your selection. You Are encouraged to
answer each question. Answering these questions will not delay your
return home. Withholding or providing inaccurate information may impair
a healthcare provider's ability to identify health problems and refer
you to appropriate sources for additional evaluation or treatment.
If you do not understand a question, please ask for help.
Demographics:
Last Name:
First Name:
Middle Initial:
Social Security Number:
Today's Date (dd/mmm/yyyy):
Gender: Male; Female:
Name of Your Unit during this Deployment:
Date of Birth (dd/mmm/yyyy):
Service Branch:
Air Force;
Army;
Coast Guard;
Marine Corps;
Navy;
GS Employee;
Other.
Component:
Active Duty;
National Guard;
Reserves;
Civilian Government Employee;
Other.
Pay Grade:
E1;
E2;
E3;
E4;
E5;
E6;
E7;
E8;
E9;
O1;
O2;
O3;
O4;
O5;
O6;
O7;
O8;
O9;
O10;
W1;
W2;
W3;
W4;
W5;
Other.
Data of arrival in theater (dd/mmm/yyyy):
Date of departure from theater (dd/mmm/yyyy):
Name of Operation:
Location of Operation. To what areas were you mainly deployed (land-
based operations for more than 30 days)?
(Please mark all that apply, including the number of months spent at
each location.)
Country 1: Time at location (months):
Country 2: Time at location (months):
Country 3: Time at location (months):
Country 4: Time at location (months):
Country 5: Time at location (months):
Occupational specialty during this deployment (MOS/AOC, NEC/NOBC, or
AFSC):
Combat specialty:
Current Contact Information:
Phone:
Cell:
DSN:
Email:
Address:
Point of Contact who can always reach you:
Name:
Phone:
Email:
Mailing Address:
Service Member's Social Security Number:
1. Overall, how would you rate your health during the past month?
Excellent;
Very Good;
Good;
Fair;
Poor.
2. Compared to before this deployment, how would you rate your health
in general now?
Much better now than before I deployed;
Somewhat better now than before I deployed;
About the same as before I deployed;
Somewhat worse now than before I deployed;
Much worse now than before I deployed.
3. During the past 4 weeks, how difficult have physical health problems
(illness or injury) made it for you to do your work or other regular
daily activities?
Not difficult at all;
Somewhat difficult;
Very difficult;
Extremely difficult.
4. During the past 4 weeks, how difficult have emotional problems (such
as feeling depressed or anxious) made it for you to do your work, take
care of things at home, or get along with other people?
Not difficult at all;
Somewhat difficult;
Very difficult
Extremely difficult.
5. How many times were you seen by a healthcare provider/physician, PA,
medic, corpsman, etc.) for a medical problem or concern during this
deployment?
6. Did you have to spend one or more nights in a hospital as a patient
during this deployment?
Yes;
No.
7. Were you wounded, injured, assaulted or otherwise hurt during this
deployment?
No;
Yes.
7a. If yes, are you still having problems related to this event?
No;
Yes;
Unsure.
8. For any of the following symptoms, please indicate whether you went
to see a healthcare provider (physician, PA, medic, corpsman, etc.),
were placed on quarters (Qtrs) or given light/limited duty (Profile),
and whether you are still bothered by the symptom now.
Symptom: Fever;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Cough lasting more than 3 weeks;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Trouble breathing;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Bad headaches;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Generally feeling weak
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Muscle aches;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Swollen, stiff or painful joints;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Back pain;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Numbness or tingling in hands or feet;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Trouble hearing;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Ringing in the ears;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Watery, red eyes;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Dimming of vision, like the lights were going out;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Chest pain or pressure;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Dizzy, light headed, passed out;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Diarrhea;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Vomiting;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Frequent Indigestion/heartburn;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Problems sleeping or still feeling tired after sleeping;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Trouble concentrating, easily distracted;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Forgetful or trouble remembering things;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Hard to make up your mind or make decisions;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Increased irritability;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Skin diseases or rashes;
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
Symptom: Other (please list):
Sick Call? Yes/No;
Qtrs/Profile? Yes/No;
Still Bothered? Yes/No.
9.a. During this deployment, did you experience any of the following
events? (Mark all that apply)
(1) Blast or explosion (IED, RPG, land mine, grenade, etc,);
(2) Vehicular accident/crash (any vehicle, including aircraft);
(3) Fragment wound or bullet wound above your shoulders;
(4} Fall;
(5) Other event (for example, a sports injury to your head) Describe:
9.b. Did any of the following happen to you, or were you told happened
to you, immediately after any of the event(s) you just noted in
question 9.a.?
(Mark all that apply):
(1) Lost consciousness or got "knocked out": No/Yes;
(2) Felt dazed, confused. or "saw stars": No/Yes;
(3) Didn't remember the event: No/Yes;
(4) Had a concussion: No/Yes;
(5) Had a head injury: No/Yes.
9.c. Did any of the following problems begin or get worse after the
event(s) you noted in question 9.a?
(Mark all that apply)
(1) Memory problems or lapses: No/Yes;
(2) Balance problems or dizziness: No/Yes;
(3) Ringing in the ears: No/Yes;
(4) Sensitivity to bright light: No/Yes;
(5) Irritability: No/Yes;
(6) Headaches: No/Yes;
(7) Sleep problems: No/Yes.
9.d. In the past week, have you had any of the symptoms you indicated
in 9.c.?
(Mark all that apply)
(1) Memory problems or lapses: No/Yes;
(2) Balance problems or dizziness: No/Yes;
(3) Ringing in the ears: No/Yes;
(4) Sensitivity to bright light: No/Yes;
(5) Irritability: No/Yes;
(6) Headaches: No/Yes;
(7) Sleep problems: No/Yes.
10. Did you encounter dead bodies or see people killed or wounded
during this deployment? (Mark that apply)
No;
Yes;
Enemy;
Coalition;
Civilian.
11. Were you engaged in direct combat where you discharged a weapon?
No;
Yes (land/sea/air).
(2) Balance problems or diziness;
(3) Ringing in the ears;
(4) Sensitivity to bright light;
(5) Irritability;
(6) Headaches;
(7) Sleep problems.
12. During this deployment, did you ever feel that you were in great
danger of being killed?
No;
Yes;
13. Have you ever had any experience that was so frightening, horrible,
or upsetting that, in the past month, you:
a. Have had nightmares about it or thought about it when you did not
want to?
b. Tried hard not to think about it or went out of your way to avoid
situations that remind you of it?
c. Were constantly on guard, watchful or easily startled?
d. Felt numb or detached from others, activities, or your surroundings?
14. Over the past month, have you been bothered by the following
problems?
a. Little interest or pleasure in doing things:
Not at all:
Few or several days;
More than half the days:
Nearly every day:
b. Feeling down, depressed, or hopeless:
Not at all:
Few or several days;
More than half the days:
Nearly every day:
15. Alcohol is occasionally available during deployments, e.g., R&R,
port call, etc. Prior to deploying or during this deployment:
a. Did you use alcohol more than you meant to? No/Yes;
b. Have you felt that you wanted to or needed to cut down on your
drinking? No/Yes;
c. How often do you have a drink containing alcohol?
Never;
Monthly or less;
2 to 4 times a month;
2 to 3 times a week;
4 or more times a week.
d. How many drinks containing alcohol do you have on a typical day when
you are drinking?
1 or 2;
3 or 4;
5 or 6;
7 to 9;
10 or more.
e. How often do you have six or more drinks on one occasion?
Never;
Less than monthly;
Monthly;
Weekly;
Daily.
16. Are you worried about your health because you were exposed to:
(Mark all that apply)
Animal bites: No/Yes;
Animal bodies (dead): No/Yes;
Chlorine gas: No/Yes;
Depleted uranium (If yes, explain): No/Yes;
Excessive vibration: No/Yes;
Fog oils (smoke screen): No/Yes;
Garbage: No/Yes;
Human blood, body fluids, body parts, or dead bodies: No/Yes;
Industrial pollution: No/Yes;
Insect bites: No/Yes;
Ionizing radiation: No/Yes;
JP8 or other fuels: No/Yes;
Lasers: No/Yes;
Loud noises: No/Yes;
Paints: No/Yes;
Pesticides: No/Yes;
Radar/Microwaves: No/Yes;
Sand/dust: No/Yes;
Smoke from burning trash or feces: No/Yes;
Smoke from oil fire: No/Yes;
Solvents: No/Yes;
Tent heater smoke: No/Yes;
Vehicle or truck exhaust fumes: No/Yes;
Other exposures to toxic chemicals or materials, such as ammonia,
nitric acid, etc. (If yes, explain): No/Yes;
17. Were you exposed to any chemicals or other hazard (industrial,
environmental, etc.) that required you to seek immediate medical care?
No/Yes.
18. Did you enter or closely inspect any destroyed military vehicles?
No/Yes.
19. Do you think you were exposed to any chemical, biological, or
radiological warfare agents during this deployment?
No;
Don't know;
Yes, explain with date and location.
20. This question assesses your personal risk for exposure to
tuberculosis or other local infectious diseases. Would you say your
INDOOR contact with local or 3rd country nationals was:
None;
Minimal (less then 1 hour per week);
Moderate (1 or more hours per week but not daily);
Extensive (at least 1 hour per day, every day).
21. Force Health Protection Measures. Please indicate which of the
following items you used during this deployment and how often you used
them.
DEET insect repellent applied to skin:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Pesticide-treated uniforms:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Eye protection (not commercial sunglasses or prescription glasses):
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Hearing protection:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
N-95 or other respirator (not gas mask):
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Pills to stay awake, like dexedrine:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Anti-NBC meds:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Pyridostigmine (nerve agent pill):
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Nerve agent antidote injector:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
Seizure/convulsion antidote injector:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
NBC gas mask:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
MOPP over garments:
Daily:
Most days:
Some days:
Never:
Not available:
Not required:
22. Did you receive any vaccinations just before or during this
deployment?
Smallpox (leaves a scar on the arm);
Anthrax;
Botulism;
Typhoid;
Meningococcal;
Yellow Fever;
Other, list:
No;
Don't know.
23. Were you told to take medicines to prevent malaria? No/Yes.
If YES, please indicate which medicines you took and whether you missed
any doses. (Mark all that apply)
Anti-malarial medications: Chloroquine (Aralen®);
Took All Pills: No/Yes.
Anti-malarial medications: Doxycycline (Vibramycin®);
Took All Pills: No/Yes.
Anti-malarial medications: Mefloquine (Lariam®);
Took All Pills: No/Yes.
Anti-malarial medications: Primaquine;
Took All Pills: No/Yes.
Anti-malarial medications: Other:
Took All Pills: No/Yes.
24. Would you like to schedule a visit with a healthcare provider to
further discuss your health concern(s)?
No/Yes.
25. Are you currently interested in receiving information or assistance
for a stress, emotional or alcohol concern?
No/Yes.
26. Are you currently interested in receiving assistance for a family
or relationship concern?
No/Yes.
27. Would you like to schedule a visit with a chaplain or a community
support counselor?
No/Yes.
Health Care Provider Only:
Post-Deployment Health Care Provider Review, Interview, and Assessment:
1. Do you have any medical or denial problems that developed during
this deployment?
No/Yes.
If yes, are the problems still bothering you now?
No/Yes.
2. Are you currently on a profile (or LIMDU) that restricts your
activities (light or limited duty)?
No/Yes.
If yes: For what reason?
Is your condition due to an injury or illness that occurred during the
deployment?
Yes/No/NA.
Did you have similar problems prior to deployment?
Yes/No/NA.
If so, did your condition worsen during the deployment?
Yes/No/NA.
3. Ask the following behavioral risk questions. Conduct risk assessment
as necessary.
a. Over the past month, have you been bothered by thoughts that you
would be better off dead or of hurting yourself in some way?
Yes/No.
If yes, about how often have you been bothered by these thoughts?
A few days;
More than half of the time;
Nearly every day.
b. Over the past month, have you had thoughts or concerns that you
might hurt or lose control with someone?
Yes/No/Unsure.
4. If member reports yes or unsure responses to 3.a. or 3.b., conduct
risk assessment.
a. Does member pose a current risk for harm to self or others?
No, not a current risk;
Yes, poses a current risk;
Unsure.
b. Outcome of assessment:
Immediate referral;
Routine follow-up;
Referral not indicated.
5. Alcohol screening result:
No evidence of alcohol-related problems;
Potential alcohol problem (positive response to either question 15.a or
15.b and/or Audit-C (questions 15.c-e.) score of 4 or more for men or 3
or more for women;
Refer to PCM for evaluation: Yes/No.
6. During this deployment have you sought, or do you now intend to
seek, counseling or care for your mental health?
Yes/No.
7. Traumatic Brain Injury (TBI) risk assessment:
No evidence of risk based on responses to questions 9.a.-d.
Potential TBI with persistent symptoms, based on responses to question
9.d.
Refer for additional evaluation: Yes/No.
8. Tuberculosis risk assessment, based on response to question 20.
Minimal risk;
Increased risk;
Recommend tuberculosis skin testing in 60-90 days: Yes/No.
9. Depleted Uranium (DU) risk assessment, based on responses to
question 16 (DU, Yes) or question 18 (Yes).
No evidence of exposure to depleted uranium;
Potential exposure to depleted uranium.
Refer to PCM for completion of DD Form 2872 and possible 24-hour
urinalysis: Yes/No.
10. Do you have any other concerns about possible exposures or events
during this deployment that you feel may affect your health?
Yes/No.
Please list your concerns:
11. Do you currently have any questions or concerns about your health?
Yes/No.
Please list your concerns:
Health Assessment:
After my interview/examination of the service member and review of this
form, there is a need for further evaluation and follow-up as indicated
below. (More than one may be noted for patients with multiple problems.
Further documentation of the problem evaluation is to be placed in
service member's medical record.)
11. Identified Concerns:
Physical symptom(s):
Minor concern;
Major concern;
Already under care? Yes/No.
Exposure symptom(s):
Minor concern;
Major concern;
Already under care? Yes/No.
Environmental:
Minor concern;
Major concern;
Already under care? Yes/No.
Occupational:
Minor concern;
Major concern;
Already under care? Yes/No.
Combat or mission-related:
Minor concern;
Major concern;
Already under care? Yes/No.
Depression symptoms:
Minor concern;
Major concern;
Already under care? Yes/No.
PTSD symptoms:
Minor concern;
Major concern;
Already under care? Yes/No.
Anger/Aggression:
Minor concern;
Major concern;
Already under care? Yes/No.
Suicide Ideation:
Minor concern;
Major concern;
Already under care? Yes/No.
Social/Family conflict:
Minor concern;
Major concern;
Already under care? Yes/No.
Alcohol use:
Minor concern;
Major concern;
Already under care? Yes/No.
Other:
Minor concern;
Major concern;
Already under care? Yes/No.
12. Referral information:
Primary care, family practice:
Within 24 hours:
Within 7 days:
Within 30 days.
Behavioral health in family care:
Within 24 hours:
Within 7 days:
Within 30 days.
Mental health specialty care:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Audiology:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Cardiology:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Dentistry:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Dermatology;
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, ENT:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, GI:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Internal medicine:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Neurology:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, OB/GYN:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Opthamology:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Optometry:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Orthopedics;
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Pulmonology:
Within 24 hours:
Within 7 days:
Within 30 days.
Other specialty care, Urology:
Within 24 hours:
Within 7 days:
Within 30 days.
Case manager:
Within 24 hours:
Within 7 days:
Within 30 days.
Substance abuse program:
Within 24 hours:
Within 7 days:
Within 30 days.
Health promotion, health education:
Within 24 hours:
Within 7 days:
Within 30 days.
Chaplain:
Within 24 hours:
Within 7 days:
Within 30 days.
Family support, community service:
Within 24 hours:
Within 7 days:
Within 30 days.
Military OneSource:
Within 24 hours:
Within 7 days:
Within 30 days.
Other:
Within 24 hours:
Within 7 days:
Within 30 days.
No referral made:
Within 24 hours:
Within 7 days:
Within 30 days.
I certify that this review process has been completed: (Provider's
signature and stamp):
Date: (dd/mmm/yyyy):
This visit is coded by V70.5_E.
14. Member was provided the following:
Medical Threat Debrief;
Health Education and Information;
Health Care Benefits and Resources Information;
Appointment Assistance;
Service member declined to complete form;
Service member declined to complete interview/assessment;
Service member declined referral for services;
LOD;
Post-deployment blood specimen collected (if required).
15. Referral was made to the following healthcare or support system:
Military Treatment Facility;
Division/Line-based medical resource;
VA Medical Center or Community Clinic;
Vet Center;
TRICARE Provider;
Contract Support:
Community Service:
Other:
None:
Source: DOD.
Appendix II: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
May 16, 2008:
Ms. Cynthia A. Bascetta:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Bascetta:
This is the Department of Defense response to the Government
Accountability Office (GAO) draft report, GAO-08-615, "DoD Health Care:
Mental Health and Traumatic Brain Injury Screening Efforts Implemented,
But Consistent Pre-Deployment Medical Record Review Policies Needed,"
dated April 18, 2008 (GAO Code 290634).
Thank you for the opportunity to review and comment on the draft
report. I appreciate the collaborative, insightful, and thorough
approach your team has taken with this important issue. I also
appreciate your acknowledgement in the report of the efforts the
Department is making to ensure the deployability of Service members, to
afford follow-on care for Service members who indicate symptoms pre- or
post-deployment, and to provide training of health care providers.
Your concerns regarding clinician review of medical records are well-
taken. An assessment is only complete when it includes medical record
review, and we require such reviews take place as a vital part of our
annual periodic health assessment. I will update the Department of
Defense Instruction 6490.03, "Deployment Health," to require a medical
records review for any significant change in health status since the
most recent periodic health assessment for each Service member
undergoing a pre-deployment health assessment. The update will occur
during the next regular update of this instruction.
Again, thank you for the opportunity to provide these comments. My
points of contact for additional information are Colonel Joyce Adkins
(Functional), who can be reached at ,(703) 845-3313, and Mr. Gunther
Zimmerman (Audit Liaison), who can be reached at (703) 681-4360.
Sincerely,
Signed by:
Illegible, for:
S. Ward Casscells. MD:
Enclosure: As stated:
GAO Draft Report Dated April 18, 2008:
GAO-08-615 (GAO Code 290634):
"DOD Health Care: Mental Health and Traumatic Brain Injury Screening
Efforts Implemented, but Consistent Pre-Deployment Medical Record Review
Policies Needed"
Department Of Defense Comments To The Recommendation:
Recommendation: "In order to address the inconsistency in DoD's
policies related to the review of medical record information and to
assure that health care providers have reviewed the medical record when
screening Service members prior to deployment, we recommend that the
Secretary of Defense direct the Under Secretary of Defense for
Personnel and Readiness to revise the DoD Instruction on Deployment
Health to require a review of medical records as part of the pre-
deployment health assessment."
DoD Response: The Department of Defense concurs with comment.
Comprehensive clinician reviews of medical records take place as a
vital part of our annual periodic health assessment. We will update the
Department of Defense Instruction 6490,03, "Deployment Health," to
require a medical records review for any significant change in health
status since the most recent periodic health assessment for each
Service member undergoing a pre-deployment health assessment. The
update will occur during the next regular update of this instruction.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Cynthia A. Bascetta, (202) 512-7114 or bascettac@gao.gov:
Acknowledgments:
In addition to the contact named above, Marcia Mann, Assistant
Director; Eric Anderson; Krister Friday; Lori Fritz; Adrienne Griffin;
Amanda Pusey; and Jessica Cobert Smith made key contributions to this
report.
[End of section]
Related GAO Products:
VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation
Implemented for OEF/OIF Veterans, but Challenges Remain. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-276]. Washington, D.C.:
February 8, 2008.
VA and DOD Health Care: Administration of DOD's Post-Deployment Health
Reassessment to National Guard and Reserve Servicemembers and VA's
Interaction with DOD. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
08-181R]. Washington, D.C.: January 25, 2008.
Defense Health Care: Comprehensive Oversight Framework Needed to Help
Ensure Effective Implementation of a Deployment Health Quality
Assurance Program. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-
831]. Washington, D.C.: June 22, 2007.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its
Providers Use to Make Mental Health Evaluation Referrals for
Servicemembers. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-
397]. Washington, D.C.: May 11, 2006.
Military Personnel: Top Management Attention Is Needed to Address Long-
standing Problems with Determining Medical and Physical Fitness of the
Reserve Force. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-
105]. Washington, D.C.: October 27, 2005.
Defense Health Care: Occupational and Environmental Health Surveillance
Conducted during Deployments Needs Improvement. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-903T]. Washington, D.C.: July
19, 2005.
Defense Health Care: Improvements Needed in Occupational and
Environmental Health Surveillance during Deployments to Address
Immediate and Long-term Health Issues. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-632]. Washington, D.C.: July
14, 2005.
VA Health Care: VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-287].
Washington, D.C.: February 14, 2005.
Defense Health Care: Force Health Protection and Surveillance Policy
Compliance Was Mixed, but Appears Better for Recent Deployments.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-120]. Washington,
D.C.: November 12, 2004.
VA and Defense Health Care: More Information Needed to Determine If VA
Can Meet an Increase in Demand for Post-Traumatic Stress Disorder
Services. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-1069].
Washington, D.C.: September 20, 2004.
[End of section]
Footnotes:
[1] Office of the Surgeon, Multinational Force-Iraq and Office of The
Surgeon General, United States Army Medical Command, Mental Health
Advisory Team (MHAT) IV Operation Iraqi Freedom 05-07 Final Report
(Nov. 17, 2006). The 2008 MHAT report (MHAT V) found that 18 percent of
male Army enlisted servicemembers in OIF brigade combat teams screened
positive for PTSD, depression, or anxiety. Office of the Surgeon, Multi-
National Force-Iraq, Office of the Command Surgeon, and Office of the
Surgeon General, United States Army Medical Command, Mental Health
Advisory Team (MHAT) V Operation Iraqi Freedom 06-08: Iraq Operation
Enduring Freedom 8: Afghanistan (Feb. 14, 2008).
[2] DOD states that these groups may not be representative of all Army
and Marine Corps servicemembers returning from OEF/OIF.
[3] See 10 U.S.C. § 1074f.
[4] A 2006 series of articles in the Hartford Courant reported
allegations that servicemembers with serious psychological problems
were deployed to Iraq, and that DOD's pre-deployment health assessment
was not identifying servicemembers for mental health concerns and that
referrals for further evaluation were not being made. The articles also
reported that servicemembers were reluctant to self-disclose mental
health concerns during the PDHA and PDHRA because of stigma related to
mental health issues. The concerns raised by the Courant were cited by
members of Congress in the discussion of the provisions of the John
Warner National Defense Authorization Act for Fiscal Year 2007, which
included requirements related to screening servicemembers for mental
health and TBI.
[5] DOD, An Achievable Vision: Report of the Department of Defense Task
Force on Mental Health (Falls Church, VA: June 2007).
[6] GAO, Post-Traumatic Stress Disorder: DOD Needs to Identify the
Factors Its Providers Use to Make Mental Health Evaluation Referrals
for Servicemembers, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
06-397] (Washington, D.C.: May 11, 2006). See also Related GAO Products
at the end of this report.
[7] Following a series of Washington Post articles in February 2007
that disclosed deficiencies in the provision of outpatient services at
Walter Reed Army Medical Center and raised broader concerns about the
care of returning servicemembers and veterans, three review groups were
tasked with investigating the reported problems and making
recommendations. Among the common areas of concern identified by the
three review groups was the need to better understand and diagnose TBI.
See GAO, DOD and VA: Preliminary Observations on Efforts to Improve
Health Care and Disability Evaluations for Returning Servicemembers,
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-1256T]
(Washington, D.C.: Sept. 26, 2007).
[8] A January 2008 article in The New England Journal of Medicine found
that mild TBI is strongly associated with PTSD and physical health
problems three to four months after return from a one-year deployment
to Iraq. See Charles W. Hoge et al. "Mild Traumatic Brain Injury in
U.S. Soldiers Returning From Iraq." The New England Journal of
Medicine, 358(5) (Jan. 31, 2008).
[9] Traumatic Brain Injury Task Force, Report to The Surgeon General
(May 15, 2007).
[10] Pub. L. No. 109-364, § 738, 120 Stat. 2083, 2303-04
(2006)(amending 10 U.S.C. § 1074f). In this report, we refer to this
Act as the "2007 NDAA."
[11] We were unable to conduct site visits to observe the PDHA because
this assessment is generally conducted while the servicemember is in
the combat theater.
[12] We did not conduct work related to the PDHA at Fort Richardson
because it has not served as a location for conducting the PDHA. At
Camp Lejeune, we interviewed health care providers from the Division,
Air Wing, and Logistics Group. The 2nd Marine Division (referred to as
the division in this report) is the ground combat element and consists
primarily of Marine infantrymen. The Air Wing includes air combat
Marines and aircrafts, such as attack jets and electronic
countermeasures aircraft. The Logistics Group is responsible for
receiving, storing, distributing, and managing supply materials and
information.
[13] We looked at Navy-specific provider training because the Navy
provides health care services to the Marine Corps.
[14] A CPG contains systematically developed recommendations,
strategies, or information that help health care providers make
decisions about appropriate health care for specific clinical
circumstances.
[15] DVBIC is a multi-site center that serves active duty
servicemembers, their dependents and veterans with TBI through medical
care, clinical research initiatives and educational programs. It is the
product of collaboration among DOD, the Department of Veterans Affairs
(VA), and two civilian partners, and is funded through DOD. In November
2007, DOD announced that the DVBIC had been integrated into DOD's new
Defense Center of Excellence for Psychological Health and Traumatic
Brain Injury, which began initial operations on November 30, 2007 and
is expected to be fully functional by October 2009.
[16] Charles W. Hoge et al. "Combat Duty in Iraq and Afghanistan,
Mental Health Problems, and Barriers to Care." The New England Journal
of Medicine, 351(1) (July 1, 2004).
[17] Office of the Surgeon et al, Mental Health Advisory Team IV
Operation Iraqi Freedom 05-07 Final Report.
[18] Office of the Surgeon et al, Mental Health Advisory Team V
Operation Iraqi Freedom 06-08: Iraq Operation Enduring Freedom 8:
Afghanistan.
[19] DOD issued a definition of TBI in October 2007. DOD defines TBI as
a traumatically induced injury or disruption of brain function as a
result of an external force, indicated by at least one of the following
signs immediately following the event: (1) loss of consciousness; (2)
memory loss; (3) confusion or any alteration in mental state; (4)
weakness, loss of balance, or other neurological problems; or (5)
intracranial lesion. A TBI is classified as "mild" if it involves a
loss of consciousness of 30 minutes or less, an alteration of
consciousness up to 24 hours, and post-traumatic amnesia of one day or
less.
[20] Charles W. Hoge et al. "Mild Traumatic Brain Injury in U.S.
Soldiers Returning from Iraq." The New England Journal of Medicine,
358(5) (Jan. 31, 2008).
[21] The CPG was developed by a working group that included military
and civilian experts.
[22] See Centers for Disease Control and Prevention, [hyperlink,
http://www.cdc.gov/ncipc/pubes/tbi_toolkit/physicians/mtbi/management.ht
m] (accessed Feb. 7, 2008).
[23] DOD Instruction 6490.03, Deployment Health, Aug. 11, 2006.
[24] According to a DOD official, the Marine Corps began using the new
DD 2796 on March 11, 2008, and the Army is performing selected pilot
tests of the new form with full implementation expected after April 1,
2008.
[25] The 2007 NDAA required DOD to include an assessment of a
servicemember's current mental health conditions and treatment
following deployment, as well as an assessment of a servicemember's use
of medications for a mental health condition, in the PDHA.
Servicemembers' use of medications for a mental health condition would
be discussed during the provider interview based on the servicemembers'
responses to the mental health-related questions on the DD 2796.
[26] Independent duty medical technicians and IDCs are enlisted
personnel who receive advanced training to provide treatment and
administer medications.
[27] Military OneSource is a service that provides information and
community-based counseling resources for servicemembers and their
families.
[28] In this report, unless otherwise noted the pre-deployment health
assessment and the PDHA refer to the entire health assessment process,
which includes the servicemember's completion of the form, the review
of the form by the health care provider, and, if applicable, the health
care provider's interview with and referral of the servicemember for
further evaluation. DD 2795 and DD 2796 refer, respectively, to the pre-
deployment health assessment and PDHA forms themselves.
[29] AHLTA implementation began in January 2004 with the incorporation
of servicemembers' outpatient encounters into AHLTA records.
Enhancements to the current system are rolled out in phases. For
example, DOD will begin incorporating servicemembers' dental and vision
information into AHLTA records in 2008, and the last phase, scheduled
in 2016, will add inpatient data. AHLTA, once fully implemented, is
intended to store the servicemembers' complete electronic health
record, including inpatient and outpatient information.
[30] Pub. L. No. 109-364, § 738(c), 120 Stat. at 2303 (to be codified
at 10 U.S.C. § 1074f(f)). The Act specified that (1) the Secretary of
Defense was to prescribe in regulations minimum mental health standards
for deployment to a combat operation or contingency operation; (2) the
standards were to specify the mental health conditions, treatment, and
medications that would preclude deployment and include guidelines for
deployability and treatment of servicemembers with a mental health
condition; and (3) the Secretary was to ensure the standards were
utilized in making deployability determinations. According to a July
2007 DOD report on implementation of these provisions, a regulation is
under development to identify medical standards for all deployers.
[31] Assistant Secretary for Defense, Health Affairs, "Policy Guidance
for Deployment-Limiting Psychiatric Conditions and Medications," Nov.
7, 2006.
[32] Psychotropic medications are those capable of affecting the mind,
emotions, and behavior.
[33] Pub. L. No. 109-364, § 738(a) (to be codified at 10 U.S.C. §
1074f(b)(2)).
[34] DOD, Report on the Enhanced Mental Health Screening and Services
for Members of the Armed Forces: In Response to Section 738 in the John
Warner National Defense Authorization Act for Fiscal Year 2007 (June
2007).
[35] Program Director for Mental Health Policy, Office of the Assistant
Secretary of Defense (Health Affairs).
[36] Providers at two installations also had access to the hard copy or
electronic medical record during the pre-deployment health assessment.
[37] Although we also conducted a site visit to Fort Richardson,
Alaska, we were unable to include it in our discussion of PDHA mental
health referral tracking because this installation does not conduct the
PDHA.
[38] DOD has a Force Health Protection Quality Assurance Program. This
program includes periodic reporting on referrals indicated on the PDHA,
and follow-up medical visits accomplished. The program also includes
military-service specific quality assurance program reports that are to
include accomplishment of the PDHA and related requirements such as
referrals. However, the program is not designed to track individual
completion of referrals from the PDHA for the purpose of monitoring
follow-up care for an individual servicemember.
[39] The Deployment Support Group supports Marine Reserve members who
complete the pre-and post-deployment health assessment process at Camp
Lejeune. It was created in 2003 under the orders of the installation's
Commanding General.
[40] Health care providers such as physicians may receive their basic
medical education prior to entering the military. DOD's medical school
at the Uniformed Services University of the Health Sciences graduates
approximately 150 physicians per year. The DOD medical corps had 11,516
physicians in fiscal year 2006. IDCs are trained at the Naval School of
Health Sciences in San Diego, CA.
[41] Specifically, a 2006-2007 questionnaire completed by 125 U.S.
medical schools found that the average length of psychiatry clerkships-
-education that includes working with patients in supervised clinical
settings--was 7.1 weeks. See Barbara Barzansky and Sylvia I. Etzel,
"Medical Schools in the United States, 2006-2007," Journal of the
American Medical Association, vol. 298, no. 9 (2007), pp. 1071-1077.
[42] Deployment Health Clinical Center, [hyperlink,
http://www.pdhealth.mil] (accessed March 28, 2008).
[43] RESPECT-MIL stands for Re-Engineering Systems for the Primary Care
Treatment of Depression and PTSD in the Military.
[44] DOD has also included a screen for mild TBI to its PDHRA and DOD's
electronic version of the PHA. The TBI screening questions on the PDHRA
are identical to the questions on the PDHA, and the screening questions
on the PHA are slightly different from those on the PDHA because they
do not refer to a servicemember's deployment.
[45] Unlike typical clinical screening questions, which first screen
for symptoms and then screen for the cause of the symptoms, the TBI
screening questions first assess possible events that may have caused a
mild TBI and then assess symptoms. According to a DOD official, DOD's
TBI screening questions to be included in the PDHA were initially
developed by the DVBIC, modified by VA, and refined and adopted by DOD.
In April 2007, VA began implementing similar TBI screening questions
for OEF/OIF veterans to be administered by health care providers at VA
medical facilities.
[46] A recent study cited in The New England Journal of Medicine
suggests caution in interpreting responses to the TBI screening
questions because PTSD and depression may be the primary cause of the
servicemember's symptoms. See Charles W. Hoge et al. "Mild Traumatic
Brain Injury in U.S. Soldiers Returning From Iraq." The New England
Journal of Medicine, 358(5) (Jan. 31, 2008).
[47] The ANAM contains cognitive tests that have been developed by DOD,
such as the Walter Reed Performance Assessment Battery, which measures
the effect of sustained operations on memory, spatial processing,
logical reasoning, attention, cognition, and mood. The University of
Oklahoma holds the license for the ANAM and assures validation and
quality assurance of the ANAM tests.
[48] For a detailed description of the history of the ANAM and the
tests included in the assessment tool, see Dennis L. Reeves, et al,
"ANAM® Genogram: Historical perspectives, description, and current
endeavors," Archives of Clinical Neuropsychology, vol. 22S (2007), pp.
S15-S37.
[49] According to DVBIC, BTBIS was validated in a small, initial study
conducted with active duty servicemembers who served in Iraq or
Afghanistan between January 2004 and January 2005. A screen's validity
is a measure of how effective it is in identifying those who are and
are not at risk for mild TBI. The BTBIS is available at [hyperlink,
http://www.dvbic.org] (accessed April 8, 2008). See also Karen A.
Schwab et al., "The Brief Traumatic Brain Injury Screen (BTBIS):
Investigating the validity of a self-report instrument for detecting
traumatic brain injury (TBI) in troops returning from deployment in
Afghanistan and Iraq," Neurology, vol. 66, no. 5 supp. 2 (2006), p.
A235, and Karen A. Schwab, et al., "Screening for Traumatic Brain
Injury in Troops Returning From Deployment in Afghanistan and Iraq:
Initial Investigation of the Usefulness of a Short Screening Tool for
Traumatic Brain Injury," Journal of Head Trauma Rehabilitation, vol.
22, no. 6 (2007), pp. 377-389.
[50] Army officials stated that 10 to 20 percent of those screened had
experienced a mild TBI, and that about 70 percent of those experiencing
a mild TBI did not have TBI-related symptoms when they were screened.
According to a DOD official, the rates of mild TBI appear to vary based
on the location and intensity of combat to which the servicemember was
exposed in theater.
[51] The guidance is designed to provide a preliminary basis for care
of mild TBI until formal CPGs are published.
[End of section]
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