1. Soldier Readiness Processing Occupational Health Care
Fort Carson Team
Heidi Terrio, MD, MPH, COL, USA
Chief, Deployment Health
Alden Prowell, Operational Director
SEP 2008

2. FC SRC Mission Statement
To provide compassionate and comprehensive health care screening, referral, and initial treatment for every service member every visit to ensure Warrior resilience and readiness.

3. SRC Goals
Provide Excellent Customer Service
Comprehensive Service
Multidisciplinary Approach
One Stop for Deployment Issues
Central Tracking of non-deployable profiles, TBI, BH, and referral issues
Continuous Process Improvement

4. The One Stop Concept
The Soldier may walk-in or be scheduled
Every time the Soldier enters the SRC:
Demographic data is updated
All Unit Status Readiness (USR) data and Army Knowledge Online (AKO) issues are addressed
The Soldier is assessed in a comprehensive manner (e.g., all PULHES are evaluated)

5. Types of Services Provided
Fitness for Duty Assessment
The Pre-Deployment Health Assessment
The Post-Deployment Health Assessment (PDHA)
The Post-Deployment Health Re-assessment (PDHRA)
The Periodic Health Assessment
Traumatic Brain Injury Screening and Diagnosis
In- and Out-Processing Evaluations
Medevacs and screening for the Warrior Transition Unit (WTU)
New to SRP is the baseline ANAM
These are the types of services that we provide. Units schedule a review of all their non-deployable Soldiers. This is especially useful when Bn providers are new to their unit.

6. SRC Throughput Deploy/MOB 25 SM/provider DEMOB* 15 SM/provider
Redeploy 20 SM/provider
PHA can be done with above
Takes an extra 5-10 minutes/encounter
PDHRA 25 SM/provider
Generally have 8-10 providers onsite
* For RC must do LODs, PHA, f/u appts must be completed within 72 hrs, and offer WTU for SM that require T3 or higher profile

7. The Question of the Day
No matter what process the Soldier is doing, the question of the day is…
Is this Soldier Fit for duty in his/her Military Occupational Specialty and Soldier skills?
This is what every clinic should do. But if we do our job right the Specialist can concentrate on what they do best and that is be experts in their fields.

8. Timeline: Deployment Cycle
SRP Encounters
Training or inprocessing
Injury Event
PDHA
PDHRA
Pre-deploy
DD2900
DD2796
DD2795
Time 3
DD 2795
Time 4
MACE or ANAM
Time 0
Time 2
Time 1
Catch up on ITO History
Aver is ~ 6 m
~ 3-6 m
~ 3-6 m
~ 3-6 m
In Theater
At homecoming first 5-7 days
At days post deployment
Deploy
~7-30 days
Deployment Time 6-15 m
Dwell Time m

9. The Unit Responsibility
Must do SRP for any deployment within 30 days, re-deployment in the first 30days back, have a day reassessment, have an annual PHA and maintain Unit Readiness
Provide C2 and have medical unit provider participate
Must submit waivers to for non-deployable Soldiers when going to CENTCOM (at pre-deployment)
Have Soldiers bring profiles, ID cards to the SRC
Have the Soldiers Med and SRP Records available
At post-deployment, any databases that capture medical assessments ITO helps SRC validate injuries
These are Commander’s Programs. Unit readiness is measured by the USR data (it is a Personnel Data System run by the S1 shop).

10. Why is Fort Carson noted for Best Practice?
It is a One Stop Soldier Readiness Center regarded as an Occupational Health Clinic
Customer Service is priority
Profiles (describe medical conditions and limitations) capture non-deployable Soldiers needing recovery
Interdisciplinary approach, includes the unit medical provider
Information is translated into the EMR (AHLTA)
from MEDPROS (the operational database)
Immediate onsite diagnoses and treatment during all SRP evaluations increases satisfaction and takes less overall resources

11. Occupational Health Eval
Fort Carson has a ONE STOP SETTING!
DARTS
MEDPROS
This is what the process looks like diagrammatically. There are many stations available, everyone does not have to go to every station. The process takes about ½ day on average./
The cost is $40K/day.With 86 medical personnel involved. The information collected is put into an operational database called MEDPROS.
Other Services:
ACS
VA Liaison
TRICARE
ISOPREP
USAMITC
ANAM
See Appendix A

12. Roadmap is Individualized
Example:
Soldier moved to Fort Carson at 90 days post-deployment from OIF 4 and new unit is going to National Training Center (NTC)
On in-processing, all the following is performed
Pre-Deployment DD Form 2795 for NTC
TBI Screening (if never evaluated prior)
Periodic Health Assessment (required annually)
Post Deployment Health Reassessment DD Form 2900 ( day post-deployment)
Navigation is provided through a roadmap that the beginning start station maps out. They are also the ending station, so they can see if the Warrior actually went to all the required stations. Extra required stations are highlighted by the stations as needed e.g BH, or acute care or TBI clinical assessment.

13. The Process is to Benefit the Soldier
Deliver this information in the pre-brief for post-deployment especially
For those with symptoms, they will be treated today
Block leave will not be delayed
Goals
Identify all their issues before they leave the Army (RC, ETSing and Retiring) or ensure recovery before the next deployment
Get the best documentation into their medical record
Translate what happened to them into their permanent medical records

14. Specialized Care as Needed
Audiology Screen by Techs> Audiologist
Optometry Screen by Tech > Optometrist
Behavioral Health Screen by SRC Provider>
Master’s level LCSW> Psychiatrist
TBI Screen by SRC Provider>
TBI Clinic at SRC>Specialty Care (Neuro and BH)
All Soldiers with profiles and consults>
Organic Medical Assets reviews and validates
General Primary Care Provider reviews entire packet and QCs > Immunizations, Profiles, Specialty Consults
Medication Review> SRC Providers> PharmD

15. SRC Staffing 9-10 Providers (SRC Screening)
3 Providers, 1 CM, 1 LPN, 1 Admin (Acute Treatment)
6 LCSWs, 1 Pysch Nurse (BH Screening)
1 Audiologist, 4 Tech, 1 Admin. (Hearing Conservation)
1 Optometrist, 1 Tech, 1 Admin. (Vision Screening)
6 LPNs, 3 Phlebotomists, 2 Lab Tech (Laboratory)
7 LPNs, 1 CNA, 1 MA (Immunizations)
10 Admin., 2 QA Staff (Medical Start/Finish)
3 Profile Clerks, 1 CM, Unit Provider (PCM/CM Team)
1 Clinical PharmD, 1 Coder, 3 DVBIC Staff
1 OIC, 1 Operation Officer, 1 Assist. Op Officer

16. Medical Provider Screening Collaboration
Example of the loss of hearing and ruptured ear drum. If the Warrior says that he never had an injury event but the SRC provider sees that he had hearing loss and a ruptured ear drum, the provider can ask more about that and how that happened, because the data from one provider is available to the next.
This interdisciplinary approach provides a safe, efficient, and comprehensive approach!

17. Data Base Challenges
To Ensure translation, SRC providers must have AHLTA, TMDS, DD2766 hardcopy med record
SRC Providers must translate by either writing a good thorough consult or becoming treating providers- currently, most SRCs only screen and refer
TMDS- Theater Medical Data Store
MC4- Medical Communications for Combat Casualty Care
AHLTA is the EHR for DoD
VistA- is the HER for VA
BHIE is Bi-directional Health Info Exchange listed on the dashboard in AHLTA
CPRS/Remote Data is how to access BHIE in VistA
Referral
BHIE/CPRS

18. FC SRC FLOW Same Day /Same Site Pharm D Garrison Building
Treatment Building
Acute
Care
Injury and ANAM Eval
Same Day /Same Site
Pharm D
TBI
Unit LCSW BH
Garrison Building
Acute issues
Imm
Evaluate and Treat
Documents in AHLTA
Collateral inform
Review
all Med
Records
Endorses all profiles
SRC
Provider
Opt
His is a model of how Fort Carson gets around the database issues, promises onsite care, and uses the providers in a comprehensive and efficient manner.
Chronic issues
Unit
Provider
Lab
Profile Repository
Audio CM
Screens Triages
Documents in MEDPROS

19. Non-Deployable Soldiers
Soldiers requiring further evaluation, rehabilitation, surgery or treatment before consideration for a new deployment
Profile provided on a DD Form 3349
The SRC Provider reviews the pre-existing profiles and entire medical record
If the profile is not comprehensive, or they do not have one, the SRC Provider will write the profile
The Unit Medical Provider will validate, initial and date the bottom margin of the DD3349

20. Profiles QC’d by Profile Clerk
DD FORM 3349 TO INCLUDE:
The lay diagnosis
The Soldier limitations
In the comment box- where the Soldier is in the deployment cycle
The next step in recovery
The appointment time and date, surgery date
The expected date of full recovery
Appropriate demographics
The initials from their own PCM

21. Profile/Appointment Tracking
Profile and appointment station are combined
The Soldier is booked for an appointment
The profile clerk QCs profiles and logs into an EXCEL Share Drive – “S” Drive
If the unit medical provider has not seen the SM
SM is booked with own provider w/in 72 hrs
SM is listed in the “S” Drive EXCEL Spreadsheet in yellow highlighter notifying the Soldier’s provider that profile is new

22. Non-Deployable Soldier Tracking
All Soldiers with a non-deployable profile are case managed
The appointment clerk books with their case manager, who in turn books them with their provider
Their unit providers have read access only
Once they have seen SM, they validate the profile and when cleared the Soldier returns to SRC

23. Case Managers
Are located at the designated Troop Medical Clinics and work for Managed Care, and the Chief of the clinic
They act as the first line assistant to the unit provider and a liaison to the Commander
They track non-deployable Soldiers to ensure recovery

24. The “S” Drive List
Organized like the non-deployable Unit Status Readiness (USR) data
Allows unit providers to have visibility of all the Soldiers needing care
Their provider then keeps the Unit Commander informed on a continual basis

25. Non-Deployable Tiger Teams
Consists of representatives from the Unit Providers, SRC, Behavioral Health, Unit Chain of Command, Garrison, Primary Care, WTU
Set up to review temporary non-deployable profiles to determine Soldiers needing Warrior Transition Unit candidates (Medical Evaluation Board and profiles>180days)
Helps ensure Soldiers are being Rehabilitated
Creates a collaborative relationship between Commanders, Garrison Support and medical assets

26. Considerations for the Future
Have a Occupational Health Clinic at all posts that handle all issues that involve a Soldier’s fitness for duty issues- an all-in-one comprehensive evaluation
Performs
Annual: Periodic Health Assessment
Deployment: Predeployment, PDHA, PDHRA
Have fulltime initial treatment on walk-in basis for most common deployment Issues- TBI, BH, Audiology
Move to the whole operation from a Garrison Facility to a Medical Facility so that the treatment can be provided rather than triaged

27. Treatment Onsite in Adjacent Medical Building
SRC is a Garrison Operation (currently)
Short-term solution: Facility adjacent to SRC
Long-term solution: the medical SRC should be a MTF function (Occupational Health Clinic)
Allows initiation of care immediately
Translates the deployment issue into the electronic medical records (AHLTA)
Uses limited resources efficiently
Takes one fourth the time for definitive care because it builds on the inform obtained at SRP

28. In Summary
One Stop for all Occupational Health Issues streamlines, improves efficiency and gives a snapshot of a units readiness on an ongoing basis
Integrated, collaborative processes work better than the standard clinic processes for an occupational assessment
Profiles speak to other providers, leaders and the Soldier. Allows everyone to understand what issue is still outstanding and requires attention.

29. Process Must Benefit the Service Member
Ensure immediate treatment onsite
Offsite referrals delay treatment
Displays compassion to the Soldiers and is most cost effective to the organization
The homecoming assessment takes half a day and information is put into a data system that is unavailable to most subsequent providers–why waste the information?
Document, translate and treat immediately

30. USA MEDDAC Fort Carson, CO
"Care with Honor"

31. Appendix A: What is the ANAM?
It is for use by a trained BH Specialist in case a Soldier sustains a head injury in theater
It provides a baseline cognitive test for comparison
Issues stem from
Cognitive difficulty having a variety of reasons besides TBI; include acute stress reaction, PTSD, depression, drug side effects, sleep deprivation
Having only one baseline may not represent true baseline
It provides extra info to help with RTD issues in combat

32. ANAM4 TBI MIL Battery
Simple
Reaction Time
Mood
Scale
Sleepiness
TBI
Questionnaire
Demographics
Module
User Profile
TBI History
Fatigue
Mood State
Basic Speed 5 4 3 2 1
Simple
Reaction Time
Code Sub
(Delayed)
Matching
to Sample
Mathematical
Processing
Procedural
Code
Substitution
(Learning)
Associative Learning
Processing Speed
Working Memory
Spatial Memory
Memory 11 10 9 8 7 6
This is just a test not a screen!
* Automated Neurocognitive Assessment Metrics Required per ASDHA Dr. Cassells Memo 28 May

33. ANAM Requirements
Requires 3 staff personnel to brief, and proctor the testing process for SM/d
Requires computer terminals
Since it is only a test, not a screen, it does not require extra medical providers to interpret the results