Integrated Disability Evaluation System (IDES) Update and Provider Workshop

82 

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COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Integrated Disability Evaluation System (IDES)

– Update and Provider Workshop

Uniformed Services Academy of Family Physicians (USAFP)

Scientific Assembly

March 21, 2015

UNCLASSIFIED/FOUO

COL Niel Johnson, MD

Director, J-7, Medical Plans & Policy Directorate/Command Surgeon, USMEPCOM

OTSG Consultant, Medical Evaluation Boards & Physical Disability System

(847) 688-3680, ext. 7120

(2)

Agenda

Intro to Integrated Disability Evaluation System (IDES)

Current IDES Statistics and Trends

New Rules & Tools

Recent Challenges, Successes, and Lessons Learned

(3)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Learning Objectives

1.

Describe the Integrated Disability Evaluation System (IDES) and

explain its role in military readiness.

2.

Report current statistics and metrics in IDES, highlighting relevant

trends identifying certain at-risk populations, locations, and business

practices.

3.

Discuss recent changes to IDES policies, rules, and regulations

affecting operations impacting clinicians, administrators, and

patients.

4.

Identify lessons learned from IDES operations over the past year,

from both DoD and DVA.

(4)

Most Important Take-Away Points

The military’s Physical Disability System exists to improve

Readiness

IDES is an

administrative

medical process,

NOT

a

clinical

process

IDES

workload

has increased significantly over the past 8 years, but

standardization

and

training

have improved timeliness and quality

Heightened interest at the DoD level has driven

changes

(and for the

(5)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015

(6)

Integrated Disability Evaluation System (IDES)

IDES is the DoD’s Physical Disability System, which combines the basic

process of the traditional (a.k.a. “Legacy”) MEB system with the

Department of Veterans Affairs Compensation & Pension

Examination system.

Created in response to the issues (e.g., timeliness, quality, lack of

transparency) and dissatisfaction resulting from complex OIF/OEF

cases at Walter Reed in 2006

Primary goal of IDES is to

facilitate transition

of wounded, ill, or

(7)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

MEB uses the VA exam and the entire treatment record to develop

the IDES NARSUM which documents the DoD’s opinion whether

medical condition(s) meet/s or fail/s Army retention standards

The VA C&P Exam and Disability Benefits Questionnaire (DBQ)

support disability rating % per VASRD regulations

Army PEB determines fit/unfit & military compensability

DVA rates all service-connected conditions– the FIT, UNFIT, and

CLAIMED

Army adopts DVA rating/s for only the UNFIT conditions

IDES Overview (Cont’d)

(8)
(9)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

IDES Phases

Service

member in

treatment up

to a year

Clinician

identifies

condition that

may render SM

unfit for duty /

Refers into DES

PEBLO

counsels SM

on the DES

VA counsels

SM on benefits

/ SM identifies

additional

conditions /

schedules

exams

VA examines

all conditions

MEB identifies

all conditions

that may make

SM unfit for

duty

PEB identifies

conditions

make the SM

unfit

If unfit, VA

rates unfitting

as well as all

other Service

Connected

conditions

PEB uses VA

rating for

unfitting

conditions to

determine

Service

benefits

SM receives

DoD and VA

benefits

shortly after

discharge

Two ratings: one for unfitting

conditions; one for all Service

Connected conditions

BEN

EF

IT

S

TRANSITION

45

RE FE RRA L 10 VA C LA IM S 10 MEDICAL EXAM

45 Medical Evaluation Board 35

Physical Evaluation Board 15 VA Rating 15 Election and SA Approval 20

Planned Cycle time from Referral to VA Benefits is 295 days

Medical Evaluation Board

Physical Evaluation Board

Transition

2 3

4

5

6

7

8

9

10

TR

EA

TM

EN

T

1

Referral

Decision

Decision

Fitness

In Treatment up to a

Year (T3/T4)

+100 DAYS

+150 DAYS

Organized into 5 Phase, 10 Stages (Sub processes), with ~155 Processing Steps

8 functional activities: Counseling, Case Development, Medical Evaluation, Fitness Evaluation,

Disability Evaluation/Rating, Disposition, Appellate & Review, and Command.

ACOM, Personnel Department , Medical Department, Veterans Health, Veterans Benefits

Retention

Decision

Disposition

Decision

MRDP – P3/P4

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UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Current IDES Statistics & Trends

As of Feb 15, there are 28,635 active cases in IDES

24% (6,961) are TDRL cases

Active Component (75%), ARNG (16%), USAR (9%)

11% (2,311) are WTU Soldiers

Positive Trends (Jan ‘12 – Sept ‘13 – Feb '15):

↓ P3 →

Average MEB completion time for the total force:

201 d

→ 94 d →

83 d (goal 100 d)

Represents 83% percent completed on time.

↓ VA Rating Decision time, 158 d → 50 d →

47 d (goal 100 d)

↓ NARSUM development time, 72 d →

49 d →

7 d (goal 5 d)

58% of NARSUMs completed within the 5-day standard

↑ Total IDES time, 340 d → 430 d →

338

d (goal 295 d)

(12)

28,635 Active Cases, 9 February 2015

24% (6,961) are TDRL cases

42% of the TDRL cases are worked by Ivan Walks

Contract

Remaining 20,668 MEB Cases

2,311 (11%) are WT Soldiers

77% have already completed the MEB Phase

19,363 (89%) are Non WT Soldiers (remain with Unit)

78% have already completed the MEB Phase

3,996 WT (Warrior Transition) Soldiers

58% are in the Disability Evaluation System

45% have already completed the MEB Phase

POC: Dr. Michael J. Carino, OTSG PA&E

Source: EMEB, VTA, MODS

Disability Evaluation System Overview

Workload, 9 February 2015

(13)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015

(14)

Percent of Time in Overall

Process…and who assumes

responsibility for key phase

or stage in process

(cohorts based on month in

which phase or stage was

recorded as “complete” in

(15)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015

(16)
(17)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

USAPDA Projected vs. Actual Total Workload

29% Became TDRL 29% Became TDRL 22% Became TDRL Projected 20% TDRL 19% Projected TDRL 22% Projected TDRL

MANNING

WORKLOAD

25,351

33,080

32,159

33,280

27,660

30,288

Slide 17

(18)

Monitoring Trends

count reflects completed cases for each phase or stage since 2007 (November 2007—January 2015)…a Soldier who has completed the total IDES process

will be counted in each of his/her phase or stage at time completed)

IDES Frequency Distribution:

Phases and Stages in Process

(19)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Monitoring Trends

(count reflects completed cases for each phase or stage since 2007 (November 2007—January 2015)…a Soldier who has completed the total IDES process

will be counted in each of his/her phase or stage at time completed)

MEB Improvement and

positive shift in

distribution

NARSUM Improvement

and positive shift in

distribution

PEB negative shift

in distribution

IDES negative shift

in distribution

IDES Frequency Distribution:

Phases and Stages in Process

(20)
(21)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

New Tools

IDES Service Line

Disability Benefits Questionnaire

Integrated NARSUM

IDES Dashboard for Commanders

IDES Guidebook

Veterans Tracking Application (VTA)

Medical Management Cell

eProfile

(22)

The Army Medical Command (MEDCOM) established the IDES Service

Line (SL) to focus on increasing the efficiency of the IDES process in

September 2012.

The mission of the IDES SL is to optimize IDES processes and

procedures, helping to ensure the timeliness and accuracy of Medical

Evaluation Boards (MEBs) for wounded, ill, or injured Soldiers and

their Families

Using the framework of the Operating Company Model, the IDES SL

deploys strategy, maintains accountability, and collaborates with its

Department of Defense (DoD) and Department of Veterans Affairs

(VA) partners to centrally optimize a sustainable, standardized

process

(23)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Slide 23

G-3/5/7 Organizational Chart

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The IDES SL operates under the direction of Army Medical Readiness,

a part of the Healthcare Operations Directorate, which in turn falls

under the G-3/5/7 of Army Medical Command (MEDCOM).

MEDCOM G-3/5/7 reports directly to The Surgeon General (TSG). The

IDES SL coordinates regularly with the Office of the Secretary of

Defense (OSD) Warrior Care Policy (WCP) Office and the U.S. Army

Physical Disability Agency (USAPDA).

IDES SL partners with other Tri-Service stakeholders to inform

DoD-level policy and guidance created by the OSD WCP Office. Similarly,

IDES SL collaborates with PDA, which is part of Army G-1.

As the Army proponent for IDES, the PDA is responsible for all Army

policy related to the process.

Governance Framework

(25)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Continuous re-assessment of the resources needed to do the job

Explore all means to reduce TDRL backlog

Seek to find ways of identifying early predictors of entry into IDES

Optimizing “triage” of cases as they enter the system

Efficient workforce utilization and process improvement

Evaluation of diverse operating models such as remote NARSUMs,

centralized processing centers, etc.

Maintaining emphasis on training – new provider and sustainment

Way Ahead

New Tools – IDES Service Line (Cont’d)

(26)

Disability Benefits Questionnaire

August 2009 – President Obama’s Innovation Initiative winner

Purpose: Standardize data collection for substantiating VA rating

decisions in order to improve accuracy and consistency through use

of streamlined medical reports

IDES Purpose – Document evidence for MEB retention decisions

DBQ serves as the exam of record for IDES

Supports IDES NARSUM, providing details such as dates of onset,

treatment course, prognosis and impact to military duty

Does not change the C&P exam process, just the format

New Separation Health Assessment (SHA) General Medical Exam DBQ

was developed to allow examiners to provide additional information

for non-rating purposes

(27)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Diagnoses are listed at the

top of the SHA Gen Med DBQ

Disability Benefits Questionnaire (Cont’d)

What do DBQ’s Look Like?

Followed by:

Symptomatic Systems,

Abnormal Findings

(28)

Integrated NARSUM (iNARSUM)

In July 2012, iNARSUM became the standard to best reflect TSG’s

intent to integrate the VA exams into the IDES process

Essential features:

Simplified, 10-element outline format, lists each diagnosis

(confirmed by the VA), and includes only the information

necessary to provide the foundation for the MEB to make a

retention decision, and the PEB to make a fitness decision

Focused discussion of profile limitations

Benefits:

Decreased processing time at both MEB and PEB

Reduced unnecessary and redundant information

(29)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Not

included:

Physical exam data conducted by the MEB examiner

Rating criteria (including data used to make rating decisions)

Clinical details not directly supportive of MEB examiner conclusions (e.g.,

complete test results, consults, x-ray interpretations, etc.)

Administrative details not relevant to the MEB or PEB decision-making

process (e.g., awards and decorations, schools attended, badges,

disciplinary actions taken, etc.)

References

Annex O to OPORD 12-331 outlines the minimum necessary

requirements for writing the NARSUM

NARSUM Guidebook

USPDA Advanced MEB Course

Integrated NARSUM (Cont’d)

(30)

Summary of iNARSUM Requirements

Section Requirement

Purpose

1

Soldier Identification

BLUF identification of Soldier and purpose for the MEB

2

Sources and References

Lists specific medical evidence used in iNARSUM

3

Baseline Documentation

Summarizes key military personnel information

4

DA 3947 Block 13a Diagnoses

Lists all diagnoses upfront

5

MRDP Statement

Explains how Soldier met MRDP

6

DA 3349 Review and Discussion

Reviews, discusses, and updates (if necessary) the profile

7

Diagnoses NOT Meeting Retention

Standards

Discusses disqualifying diagnoses, WRT basis for Dx, onset,

Tx course, impact to duty, and prognosis

8

Mental Competency Statement

If applicable, standard statement WRT mental competency

(31)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

IDES Dashboard for Commanders

Launched in August 2013

Online management system for Soldiers and Commanders to view

progress through the IDES process

Improves transparency and helps manage expectations

Commanders can better track their units’ overall readiness

Soldiers have better visibility of their transition plan

Hosted on the AMEDD’s Command Management System (CMS),

linked to on Army Knowledge Online (AKO)

POC: AKO Helpdesk, (703) 704-4357

Soldiers: Track your IDES case progress online via AKO - or at:

https://cms.mods.army.mil/cms/protected/report/soldierDashboard.aspx

(32)
(33)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

IDES Dashboard for Commanders (Cont’d)

(34)

Published in Oct 2012, contains a complete

overview of IDES

Purpose is to consolidate all current

guidance, orders, and regulations and

promote a simplified, common

understanding of IDES for all stakeholders

Soldiers & Families, Commanders

IDES staff – Clinicians, PEBLOs, lawyers

VA staff – Examiners, Raters

Regularly updated online

For more info on IDES, access the IDES Guidebook at:

(35)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Nurse Case Managers assigned to line units (brigade-sized units)

Purpose is to “Positively Manage” MNR Soldiers

RTD

MRDP

Transition from Service

Essential functions include:

Provide vital coordination link between the medical treatment

facility and tenant units on the installation

Facilitate identification of and case manage MNR population

Goals:

Decrease lost duty time, promote recovery

Decrease the time to identify a Soldier’s medical retention

determination point (MRDP) and decrease IDES administrative

time

Medical Management Cell

(36)

e-Profile is an online repository and management system for physical

profiles (DA 3349) within the Medical Operational Data System

(MODS) suite that allows global tracking of Army Soldiers with

temporary or permanent medical conditions that may render them

medically not ready to deploy.

(37)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

100% use of e-Profile required – Hard copy profiles are no longer

valid

Automatically sends DA 3349 to the Commander and updates

MEDPROS

Result is greater accuracy of true NMA population

Permits more timely identification of Soldiers reaching MRDP and

entering IDES

Ref.

HQDA EXORD 223-11, Army Implementation of Electronic profile (e-Profile) and ALARACT 205/2011

eProfile (Cont’d)

(38)

Veterans Tracking Application (VTA)

Automated databases systems allow oversight of IDES progress at all

phases, across all MTFs

Data from the Veterans Tracking Application (VTA) is fed in real-time,

to provide current operating picture

(39)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Veterans Tracking Application

Reports Module: All Army

(40)

Positive trend in process time for MEB Phase (January 2012—April 2013)

Veterans Tracking Application

(41)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Fort Hood (- - - - curve) has historically performed worse

and currently performed better than MEDCOM overall

behavior

Slide 41

Automated IDES (VTA) Application

(42)

Automated IDES (VTA) Application

(43)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Recent Challenges

(44)

Recent Challenges

Chronic Adjustment Disorder

Temporary Disabled

Retirement List (TDRL)

Re-evaluations

DRAS Backlog

(45)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Chronic Adjustment Disorder (ChAD)

No longer considered a condition that may render an individual

administratively unable to perform military duty (

§

E4.13.1.4)

Now may cause Soldier to be found UNFIT

Potentially compensable by DVA

Diagnostic criteria mirror other BH diagnoses

RECOMMEND:

Increased reliance on Commanders’ assessments

Ensure other BH diagnoses have been excluded

Refs. OTSG Policy Memo, 09 JUL 2013, Referral for Chronic Adjustment Disorder into the DES

DoDI 1332.18, Physical Disability Evaluation, updated 9 AUG 2015

Chronic Adjustment Disorder

Recent Challenges

(46)

More than 17,300 are backlogged or pending re-evaluation

TDRL backlog has grown significantly over the past 4 years

Virtually no Soldiers RTD after TDRL – Readiness impact?

TDRL re-evaluations are time-consuming, difficult, lack

standardization, and are resourced variably at different MTFs

TDRL Re-Evaluations

(47)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Increased throughput

Special contract vendor assisting with backlog

Excess MEB provider capacity is being leveraged to move cases

through

New DoDI 1332.18 guidance for TDRL

If SM still fails retention standards for the unstable condition for

which he was placed on the TDRL, evaluation of other conditions is

not required

If the original unstable condition meets retention standards on

re-exam, then examination of all other conditions is required to

determine if anything else precludes RTD

Standardized TDRL Exam Format

Ref. DoDI 1332.18, Appendix 4 to Enclosure 3, para. 2D(2), IDES, dtd. 5 AUG 2014

TDRL Way Ahead

Recent Challenges

(48)

Summary of TDRL Exam Report Requirements

Section Requirement

Purpose

1

Soldier Identification

Identification of Soldier and tenure in TDRL

2

Sources and References

Lists specific medical evidence supporting TDRL opinion

3

Baseline Documentation

Summarizes key administrative & personnel information

4

List of all TDRL (and related) Dxs

Lists all TDRL diagnoses and all new conditions attributed to

the original unfitting conditions that led to TDRL

5

Summary of unstable TDRL Dxs

Summary of unfitting or unstable TDRL conditions

6

Summary of related TDRL Dxs

Summary of new TDRL-related conditions

7

Mental Competency Statement

If applicable, standard statement WRT mental competency

(49)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Record backlog at DVA for rating decisions and re-evaluations has

captured National attention

DVA implemented many initiatives to streamline processing of cases

without sacrificing accuracy and quality

IDES cases represented a small % of this backlog, but were impacted

significantly

Initial DRAS rating decision goal is 15 days

DRAS rating decisions exceeded 162 days in September 2013 for

AC Soldiers (and exceeded 166 for all components), but as of 1

March 2015 for the month ending 28 February 2015 they were

averaging 38 days for AC Soldiers (50 days for all components).

Army Medicine has provided 22 Soldiers at the Seattle DRAS site

to assist with the case processing backlog until Sept. 30, 2015.

DRAS Backlog

Recent Challenges

(50)

Reduction of 40K to 80K Active Duty planned over the next two years

Normal attrition (retirement, ETS)

Non-promotables, Chapter separations

Non-medically ready, Non-deployables

Increased # of MEBs is expected

RECOMMEND:

MRDP enforcement

Army end-strength drawdown and OEF off-ramping likely to

increase referrals, but MEDCOM maintains flexible capacity

Downsizing the Force

(51)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Recent Successes

(52)

Recent Successes

Better enforcement of

MRDP

Complexity-Based MEB

(a.k.a. “Fast Track”)

IDES Training

IDES Task Force

(53)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

The Medical Retention Determination Point (MRDP) is agreed to occur

when a Soldier’s progress appears to have stabilized, the course of further

recovery is relatively predictable, and where it can be reasonably

determined that

further treatment will not cause the Soldier to meet

retention standards

or render them capable of performing the duties

required by their office, grade, rank or rating.

MRDP will be made within

one year

of being diagnosed with a medical

condition that does not appear to meet retention standards, and may be

made earlier if the examiner determines that the member will not be

capable of returning to duty within one year.

A Soldier that has met MRDP for at least

one (1) condition

must be sent to

the MEB. Other conditions that have not caused the Soldier to meet his or

her MRDP on their own will be addressed only to the extent necessary to

allow the MEB to decide if the condition/s meet or fail retention standards.

Ref. ALARACT 065/2011 HQDA EXORD 086-11 WARRIOR TRANSITION UNIT (WTU) TREATMENT PLAN OVERSIGHT AND MEB REFERRAL

REPORTING PROCESS, DTG: 251201Z FEB 11.

MRDP Enforcement

Recent Successes

(54)

0 d

Point of Injury (POI) or Onset of Illness

Focus on establishing diagnosis and treatment

90-day temporary profile (eProfile date establishes timeline now)

GOAL is RTD

Keys to Success: (1) Ensure best clinical care possible; (2) Emphasis on RTD

90 d

Re-evaluate SM

Focus on treatment; Consider other opinions, consults, etc.

Continue 2

nd

90-day temporary profile

GOAL is still RTD

Keys to Success: (1) Consideration of all available and appropriate treatment options; (2) Keep unit informed

180 d

Re-evaluate SM

Continue to focus on treatment but also shift focus to way-ahead and work needed to build IDES case file

Continue 3

rd

90-day temporary profile

GOAL is still RTD, but also establish groundwork for possible MRDP; Ascertain stability of secondary diagnoses

Keys to Success: (1) Unit cooperation and tracking; (2) Use of VA Checklists to identify IDES requirements

270 d

Re-evaluate SM

Focus is on completing evaluation of other conditions to be ready for MRDP

Continue 4

th

(and last) temporary 90-day profile

GOAL is being ready for MRDP at the 365-day mark

Keys to Success: (1) MRDP Coordination; (2) Enhanced access for specialty consults; (3) Engagement with MEB experts

MRDP

365 d

Medical Retention Determination Point:

Concept & Timeline

(55)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

In late 2011, Ft. Bragg piloted a model to co-locate all IDES resources,

C2, VA, and MMC into one clinical area

New MEB cases are classified on a 1 – 5 scale based on complexity, #

conditions, COMPO, time in service

Lower complexity cases are positively managed through all

processes, in as much a parallel manner as possible

Complexity-Based MEB

Recent Successes

(56)

Excellent results:

1

st

6 months: doubled # of cases processed

Over 900 cases completed and sent to the PEB in < 32 days

MEB providers average 17.5 cases/month

No decrement in quality — efficiencies gained are from process

revision

Lesson Learned: STRATCOM is important

MEDCOM has replicated this model across the AMEDD

Complexity-Based MEB (Cont’d)

(57)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Mandatory course for all MEB providers, taught by the U.S. Army

Physical Disability Agency

5 day TDY to Alexandria, VA

Offered about every 6 to 8 weeks (all COMPOs)

Yields a high return on investment towards provider productivity,

return rate, patient satisfaction and timeliness

Over 90% of MEB providers have been trained by the 2

nd

year of

implementation

Additional benefit seen by training PEBLOs, Legal Counselors, BH

providers, DCCSs, and other administrative support staff

MEDCOM is currently considering regional training and online

opportunities

Advanced MEB Course

Recent Successes

(58)

Sustainment training course for all MEB providers, organized by the

IDES Service Line at MEDCOM

5 day TDY to MacDill AFB, FL

Target audience is MEB Providers, PEBLOs, and other IDES Staff

Validates existing practices and updates understanding of latest

policies, practices, and procedures in IDES

Standardized core agenda is complemented by focused work groups

discussing identified challenges in IDES processing

Heavy emphasis is placed on addressing difficult and/or controversial

issues related to disability processing

Annual IDES Training Symposium

(59)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Army National Guard Annual Training for Medical Units, sponsored by

the Chief Surgeon, ARNG

US Army Reserves training for Medical Officers

Profiling 101, 201, and 301 Courses provided online or via VTC to

GME audiences, USUHS students, and primary care providers

enterprise-wide

Online (and DVD-based) versions of these courses remains a goal

Other opportunities to help educate non-IDES medical personnel on

the essentials of IDES – DCCS course, Brigade Surgeons' Course,

Annual OTSG Consultants' Meeting, MHS Conference, AMSUS, etc.

Other IDES Sustainment Training

Recent Successes

(60)

Management Cell at OTSG

providing oversight of IDES

Operationalizes IDES

Policy guidance

Metrics

Enforcement

O-6 (MD) leadership

Collaboration between DoD and

DVA at strategic level

Regular training and sharing of

best practices among MTFs

IDES Task Force

(61)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

Recent Policy Changes Related to IDES

(62)

Recent Policy Changes

DoDI 1332.18

Military Physical Profiling (i.e.,

preparing the DA 3349 Physical

Profile)

Medically-Optional (a.k.a.

(63)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Updates DoDI directives establishing the IDES, Service

responsibilities, and rules of engagement

Removes references to conditions formerly considered by DoD as not

constituting a physical disability (i.e., don't need profiled, can't

medically separate)

E.g., enuresis, personality disorders, alcoholism, drug abuse, and

other conditions may be eligible for referral into IDES if they cause

duty impairment

Conditions caused by willful neglect during a period of

unauthorized absence is NOT eligible for IDES referral

RC Soldiers referred under the non-duty-related process can appeal

their condition as related and referral should be under the

duty-related process

DoDI 1332.18

Recent Policies in IDES

(64)

Temporary Disabled Retired List (TDRL)

The TDRL periodic re-evaluation for cases referred under IDES

(and Legacy) will address only the condition/s for which the

Soldier was placed on the TDRL and any conditions caused by or

directly related to the treatment of the unstable condition

VA ratings given and VA exams performed since the member was

placed on TDRL may substitute for the TDRL periodic examination

Presumption of Fitness Rule now states that acute conditions

incurred within the presumptive period no longer must be of a

“grave” nature to overcome the presumption of fitness

DoDI 1332.18 (Cont’d)

(65)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Informal PEB (IPEB) must be comprised of at least two military

personnel (O4/O-5) or civilian equivalent or higher

Formal PEB (FPEB)

For Formal hearings at the PEB, E-9's may serve on enlisted

formals

FPEB must be comprised of at least three members and may be

comprised of military and civilian personnel representatives.

A majority of FPEB members could not have participated in the

adjudication process of the same case at the IPEB

Soldiers may waive referral to the PEB with the approval of the

Secretary of the Military Department (some exceptions may apply)

Fitness standards for General, Flag, and Medical Officers have been

deleted

DoDI 1332.18

Recent Policies in IDES

(66)

A “

medically-optional

surgery” is defined as one that may be

beneficial but is not required to preserve the life of the patient,

prevent the loss of function, or return the Soldier to an otherwise

Fit-for Duty status

Examples: Vasectomy, LASIK, Diagnostic arthroscopy (of uninvolved

joint, bunionectomy, cosmetic surgery

Impact:

Soldiers remain in an unresolved IDES status indefinitely

Unit Medical Readiness (UMR) remains stagnant, as Soldier is

unable to be replaced at the unit

Existing conditions that led to IDES tend to worsen (and increase

in number) over longer periods of time

Elective Surgery

(67)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Soldiers in IDES who underwent an elective surgery could not

continue processing in IDES, due to one or more reasons:

VA cannot conduct a rating exam (e.g., knee in cast, scars not healed)

PEB cannot adjudicate fitness on a condition that is not yet stabilized

(e.g., is repaired shoulder fitting or unfitting after full rehab completed)

Complications, though uncommon, can lead to further diagnoses

requiring their own work-up in IDES as potentially disabling condition/s

Frequent, and in many cases, long-term (> 6-12 month) rehabilitation

was necessary, and interfered with going to IDES appointments

Continued treatment, not intended to yield a RTD within the time

allowed per MRDP rules, ran counter to the intent of the regulation,

which is to promote RTD, transition MNA Soldiers from Service, and

improve overall Service readiness

Elective Surgery (Cont’d)

Recent Policies in IDES

(68)

MEDCOM Policy Memo 11-038 states that medically-optional

surgery will not be performed while the Soldier is being evaluated in

IDES due to the potential delay to the return to duty or the

completion of the disability evaluation, irrespective of the

anticipated disposition of the Soldier

Any Soldier who, after being told by a competent medical authority

that a treatment is unwarranted for a given medical condition, elects

to have such treatment done at their own expense will NOT be

eligible for compensation

Elective Surgery (Cont’d)

(69)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Policy changes:

Soldiers whose referred condition requires ongoing surgery for

the prevention of pain, improvement of function, or like benefit,

can be authorized to have the surgery done

Commanders assume the risk that approving medically-optional

surgery will delay IDES processing, potentially lead to further

complications (and disability), and their unit's

Medically-Non-Available % will continue to remain while the Soldier is unable to

continue processing through the IDES process

Elective Surgery (Cont’d)

Recent Policies in IDES

(70)

G37 Medical Readiness is actively participating in working groups

with FORSCOM, TRADOC, IMCOM, Army G1 and Army G3 charged

with separating and redefining temporary and permanent profile

forms to provide better visibility of medical readiness to

commanders. The group expects to have drafts by the end of

February 2015, which will then go out for internal then HQDA

staffing.

The intent behind separating out the temporary and permanent

profile comes out of recognition that the permanent profile form

relays the limitations for Service members, whereas the Temporary

profile form communicates the capabilities of Service Members and

focuses on their rehabilitation.

Profiling

(71)

UNCLASSIFIED

29 November 2010

COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / Iamthe.presenter@us.army.mil COL Niel Johnson, MD / (910) 643-4794 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO

UNCLASSIFIED

3/10/2015

Profiling (Cont’d)

Recent Policies in IDES

(72)

IDES is the process for physical disability processing

across DoD

All Services have unique requirements regarding retention and

therefore vary in the implementation of DoD policy

The ultimate goal of IDES is

Army Readiness

by either returning

Soldiers to duty or properly transitioning them to Veteran status with

appropriate compensation

In 2012, Dept. of the Army G-1 assumed

operational control

of IDES

from MEDCOM, emphasizing its importance in the eyes of line

commanders

Efforts to

standardize, simplify, and properly resource

the IDES

process are showing outstanding return on investment

(73)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

IDES Guidebook, Oct 2012

HQDA EXORD 080-12, Army Disability Evaluation System (DES) Standardization, 17 Feb 12

MEDCOM OPORD 12-31, MEDCOM Implementation of the IDES, 17 July 12

DTM 11-015, Integrated Disability Evaluation System (IDES), 03 May 12

ALARACT 065/2011 HQDA EXORD 086-11 Warrior Transition Unit Treatment Plan Oversight and

MEB Referral Reporting Process, 25 Feb 11

DODI 1332.18, Physical Disability Processing, 9 Aug 15

AR 40-400 – http://www.apd.army.mil/pdffiles/r40_400.pdf

AR 635-40 – http://www.apd.army.mil/pdffiles/r635_40.pdf

AR 600-60 – http://www.apd.army.mil/pdffiles/r600_60.pdf

AR 40-501 – http://www.apd.army.mil/pdffiles/r40_501.pdf

Websites

U.S. Army Physical Disability Agency – https://www.hrc.army.mil/SITE/Active/TAGD/Pda/pdapage.htm

Deployment Health Clinical Center – http://www.pdhealth.mil/hss/des.asp

U.S. Army Human Resources Command –

https://www.hrc.army.mil/site/Active/tagd/Pda/ArmyPDES.html

References

(74)

Integrated Disability Evaluation System (IDES)

– Update and Provider Workshop

Uniformed Services Academy of Family Physicians (USAFP)

Scientific Assembly

March 21, 2015

COL Niel Johnson, MD

Director, J-7, Medical Plans & Policy Directorate/Command Surgeon, USMEPCOM

OTSG Consultant, Medical Evaluation Boards & Physical Disability System

(847) 688-3680, ext. 7120

(75)

Select SLIDE MASTER to Insert Briefing Title Here

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

The Army’s Home for Health…

Saving Lives and Fostering Healthy

and Resilient People

(76)
(77)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

TDRL Exam Report Format

(78)

TDRL Exam Report Format

1.

Soldier Identification (Section One)

Includes the Soldier’s name, rank, and the primary military occupational

specialty (PMOS) or area of concentration (AOC) corresponding to the PMOS or

AOC alpha-numeric code.

Also includes Soldier’s maximal TDRL tenure.

2. Sources and References (Section Two)

Identify critical documents before performing an analysis and formulating

conclusions.

Support a particular finding.

TDRL examiners will reference additional documents i.e. relevant diagnostic

testing of the Soldier’s Service Treatment Record (STR), AHLTA records, and

all memorialized oral communication.

DO NOT

reference all treatment notes, just the relevant parts that support

the findings

Finalize this section after completing Sections 3-8.

3. Baseline Documentation (Section Three)

Provided by the PEBLO, available from electronic record data repository used

in IDES processing

DA 199 (PEB findings) lists all diagnoses that originally placed the Soldier

on the TDRL

DA Form 3947 (MEB findings) listing all referred, claimed, and VA diagnoses

considered by the MEB

(79)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

TDRL Exam Report Format (Cont’d)

4. Diagnoses Summary (Section Four)

IDES TDRL Examination

List all diagnoses for which Soldier was placed on TDRL (unfitting

conditions)

List all diagnoses that have developed since the Soldier was placed on the

TDRL that are due to the “unstable / unfitting condition(s)” or their

treatment.

5. Diagnosis Rated as Unstable / Unfitting (Section Five)

Utilize the applicable DBQ and VA worksheet to examine each “Unstable /

Unfitting diagnosis”

http://www.benefits.va.gov/PREDISCHARGE/disability-exams.asp

It is acceptable to complete all or part of the VA worksheet by hand

Section B of the VA Worksheet (Present Medical History) requires detailed

discussion.

Section C (Physical Examination) requires detailed documentation of specific

findings..

(80)

TDRL Exam Report Format (Cont’d)

5. Diagnosis Rated as Unstable / Unfitting (Section Five)

Attach VA Worksheet to the TDRL report for submission to the PEB.

NOT ALL diagnoses have their own VA worksheets.

Impact on Duty Performance

Discuss profile limitations, if any.

Discuss impact on PMOS/AOC.

Prognosis Statement

Consider the Soldier’s maximal TDRL tenure and whether the prognosis has

changed since being placed on TDRL.

Provide one of the four prognosis statements:

1.

Likely to improve to permit full duty performance.

2.

Likely to significantly deteriorate.

3.

Unlikely to either improve to permit return to duty or to

significantly deteriorate.

4.

Cannot opine without resort to mere speculation.

Include a discussion explaining the basis for rendering one of the four

prognoses.

(81)

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

UNCLASSIFIED

TDRL Exam Report Format (Cont’d)

6. New Diagnoses / Conditions Related to “Section Four

Diagnoses” or their treatment (Section Six)

Rationale for relationship between new condition and “Section Four Diagnoses

Summary”.

This will be based on a review of the medical records where a provider has

provided an explanation, or on general medical principles.

If Section Four Diagnosis Summary contains a mental disorder, discuss what

signs and symptoms the Soldier is currently manifesting that are better

classified as an alternate mental disorder. The TDRL examiner can discuss the

“new” condition in this section and/or explain the evolution within the

medical history section.

7. Mental Competency Statement, when applicable (Section

Seven)

Indicate whether the Soldier is mentally competent for pay purposes, capable

of understanding the nature of, and cooperating in, PEB proceedings, and/or

dangerous to themselves or others.

IDES TDRL Examination

List all diagnoses for which Soldier was placed on TDRL (unfitting

conditions)

List all diagnoses that have developed since the Soldier was placed on the

TDRL that are due to the “unstable / unfitting condition(s)” or their

treatment.

(82)

TDRL Exam Report Format (Cont’d)

8. Noncompliance, when applicable (Section Eight)

IAW AR 600-20 (Army Command Policy), 5-4 (Command Aspects of Medical Care),

the TDRL examiner writes a statement to confirm that the Soldier complied

with recommended treatments.

When the TDRL examiner has concerns regarding the Soldier’s compliance with

treatment, review AR 600-20, Ch. 5-4. e to determine whether to initiate a

medical board.

Treatment noncompliance can be a basis for disciplinary action.

Unless the preponderance of evidence supports the finding of noncompliance,

the TDRL examiner should not deem the Soldier “non-compliant.”

Figure

Updating...

Related subjects :