Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 84Case Management Version 3.0Medical Management Guidethe increase of incidences of severe physical andpsychological trauma among Service membersserving in Global War on Terror (GWOT) missions,specifically, Operation Enduring Freedom (OEF) andOperation Iraqi Freedom (OIF) (see also AppendixC, Definitions).The ongoing deployments related to the GWOThave taken a disproportionate toll on ADSMsand their families. The incidence of PTSD hasincreased, especially in ADSMs experiencingmultiple deployments. TBI has been describedas the “signature injury” of OEF and OIF. Ofteninvisible, particularly in those with mild to moderateinjury, many of these cases were missed in theearly days of the conflict. Today, identification andtreatment of this condition is much improved. Nowall returning ADSMs are screened for blast exposureand TBI. It is not uncommon for an ADSM to bediagnosed with both PTSD and TBI, each of whichrequires treatment and intervention. These ADSMsneed and benefit from CM during their recovery,but early recognition and intervention are key tosuccessful rehabilitation.The intent of the NDAA is to ensure that allwounded, ill, and injured ADSMs have the benefitof both clinical and non-clinical CM, and that casemanagers working with wounded, ill, and injuredADSMs receive appropriate training, includingtraining on PTSD and screening for TBI. Becausepatients’ psychological health often affects theirphysical recovery, case managers must be trainedto recognize behaviors that may indicate substanceabuse, depression, or other psychological crisis. Inthis respect, case managers should become familiarwith normal coping mechanisms and the stages ofloss and grief.In many managed care models, physical andbehavioral services and care are segregated. Thisalso means that physical illnesses are assessed andmanaged independently of psychosocial conditions.Yet for those suffering from chronic or complexconditions, a common profile for wounded, ill,and injured Service members, segregated careresults in poor outcomes, higher utilization ofhealthcare services, and increased impairment anddisability.A patient with chronic disease is more likely to havebehavioral or psychosocial co-morbidities. Further,medical and behavioral complexities affect overallhealth outcome, use of healthcare services, qualityof life, and treatment adherence (Steifel, 2006).PTSD and TBI can place great stress on the ADSM’sfamily as well. The case manager plays a critical rolein identifying additional resources and programs thatenhance the ability of family members to cope withand manage the challenges associated with a PTSDor TBI diagnosis.Additionally, the case manager’s body ofknowledge should include an understanding of thefollowing factors that can affect ADSM patients:• Cultural issues, including those faced by patientsliving in foreign countries.• Family dynamics and the impact of the militarylifestyle on families.• Health expectations and behaviors, includingdemands placed on fit warrior expectations.• Psychological and neuropsychologicalassessments, especially post-deployment anddepression screening.• The psychological impact of chronic illness anddisability.
Medical Management GuideVersion 3.0Case ManagementPage 85• Substance use/abuse/addiction, including theuse of dietary supplements.Disability Evaluation SystemWhen an ADSM suffers from an injury or a chronicillness, the MTF’s primary responsibility is to providemedical treatment, with the ultimate goal ofreturning the ADSM quickly to duty. However, someof these patients may be unable to perform theirduties and will be required to enter the DisabilityEvaluation System (DES). The DES has two distinctstages: the Medical Evaluation Board (MEB) and thePhysical Evaluation Board (PEB).Medical Evaluation BoardThe MEB is typically made up of two or threephysicians who evaluate the ADSM’s injury orillness and plan of care to make a determinationon whether the ADSM can adequately perform theassigned duties of his/her position. The ADSM istypically referred to the MEB by the primary careprovider or the unit Commander; or the referral maybe based on a higher-Command recommendation.If the ADSM is found fit for duty, the MEB will clearthe ADSM and return him/her to duty. If the MEBfinds that the ADSM may return to Active Duty andperform his/her duties within a reasonable period oftime (typically between eight and 16 months withtreatment), the Board may recommend TemporaryDuty (TDY) for the ADSM. If the MEB determinesthat the ADSM is unfit for continued duty, the Boardrefers the patient to the PEB.Physical Evaluation BoardThere are two types of PEB: informal and formal.The informal PEB (IPEB) is the first step in the PEBprocess and is defined by the following aspects:• It includes three voting members — one mustbe a physician and one must be a nonmedicalofficer.• The ADSM may not be physically present.• The ADSM may agree with the recommendationof the IPEB or request reconsideration at aformal PEB.The formal PEB is defined by the following aspects:• It includes three voting members — one mustbe a physician and one must be a nonmedicalofficer.• It allows the ADSM to appear before the board,present evidence and testimony, call witnesses,review all documents used by the board, andprovide any additional documents he/she deemsimportant to his/her case.• The ADSM is generally represented by anattorney.A final determination from the formal PEB will beone of the following:• Separation without Benefits• Separation with Severance Pay• Permanent Disability Retirement (PDR)• Temporary Disability Retirement List (TDRL)• Return to DutyThe ADSM has a right to appeal the formal PEBdetermination through his/her Service’s appellatereview agency. Certain ADSMs who are determinedto be unfit for duty may be able to remain on Active
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