Integrated Disability Evaluation System (IDES) Update and Provider Workshop

(1)

COL Niel Johnson, MD / (847) 688-3680 / [email protected] UNCLASSIFIED // FOUO 3/10/2015 COL Niel Johnson, MD / (847) 688-3680 / [email protected]

_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)

_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 / [email protected] 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) / [email protected] COL Niel Johnson, MD / (910) 643-4794 / [email protected] COL Niel Johnson, MD / (847) 688-3680 / [email protected] COL Niel Johnson, MD / (847) 688-3680 / [email protected] 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)

_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

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

(10)

(11)

UNCLASSIFIED

29 November 2010

_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)

(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)

(16)

(17)

_UNCLASSIFIED

USAPDA Projected vs. Actual Total Workload

29% Became TDRL 29% Became TDRL _22% Became TDRL _Projected20% 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)

_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

_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

_UNCLASSIFIED

3/10/2015

Slide 23

G-3/5/7 Organizational Chart

(24)



_{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)

_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)

_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

_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

_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)

_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

_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

_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)

_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)

_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)

_UNCLASSIFIED

Recent Challenges

(44)

Recent Challenges



_{Chronic Adjustment Disorder}



_{Temporary Disabled}

Retirement List (TDRL)

Re-evaluations



DRAS Backlog

(45)

UNCLASSIFIED

29 November 2010

_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

_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

_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)

_UNCLASSIFIED

Recent Successes

(52)

Recent Successes



_{Better enforcement of}

MRDP



_{Complexity-Based MEB}

(a.k.a. “Fast Track”)



IDES Training



_{IDES Task Force}

(53)

_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)

_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

_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

_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)

_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

_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

_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

_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

_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

_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)

_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

_UNCLASSIFIED

The Army’s Home for Health…

Saving Lives and Fostering Healthy

and Resilient People

(76)

(77)

_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)

_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)

_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.”