The Australian Defence Force (ADF) Post-discharge GP Health Assessment was developed by the Department of Veterans’ Affairs (DVA) as part of the Veteran mental health strategy: A ten year framework 2013–2023 initiative.1 The health assessment was designed to assist former ADF personnel to access primary healthcare after their discharge. Between 5000 and 6000 personnel leave the ADF each year and many will not have had contact with the Medicare health system for several years; some will have had no contact with Medicare at all as an adult. The health assessment seeks to promote the early detection and intervention of any potential mental or physical health concerns so that the general practitioner (GP) can refer the patient to specialist services, if required.
The assessment is funded under the Medicare Benefits Schedule (MBS) time-based health assessment items 701 (brief), 703 (standard), 705 (long) and 707 (prolonged).2 The health assessment can be performed at any point after the patient’s discharge from the ADF. The assessment is available to all former ADF members, whether or not they are a DVA client. The health assessment can only be performed once at a single point in time. Currently, the optimal time to perform the assessment following discharge from the ADF is not known. It is intended that the health assessment is performed by the veteran’s usual medical practitioner. Practice nurses and Aboriginal and Torres Strait Islander health practitioners may assist medical practitioners in performing the health assessment.3
Components of the ADF Post-discharge GP Health Assessment
The ADF Post-discharge GP Health Assessment requires the practitioner to record the patient’s history, including:
- service with the ADF – service type, years of service, field of work, deployments and reason for discharge
- social history – relationship status, number of children, current occupation
- current medical conditions.
The health assessment should also cover a range of other health domains where these are applicable (Table 1).2
Patients should be provided with an explanation of the health assessment process and its likely benefits. Consent to perform the assessment should be obtained and noted in patients’ records. Patients should be assured that the information they provide will be treated as confidential.
Table 1. Key components of the ADF Post-discharge GP Health Assessment
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| Mandatory | Where applicable |
|---|
A brief ADF service history
- Type of military service
- Years of service
- Field of work
- Number of times deployed
- Reason for discharge
Social history
- Relationships
- Number of children
- Current occupation
Current medical conditions
|
Basic physical examination
- Blood pressure
- Waist circumference
- Body mass index (BMI)
Use of medication
Post-military physical and mental health
- Hearing
- Pain
- Sleep
- Psychological distress
- Post-traumatic stress disorder
- Level of physical activity
- Sexual health
- Anger
- Risk of harm to self or others
Behavioural risk factors
- Alcohol
- Substance use
- Smoking
|
The ADF Post-discharge GP Health Assessment tool
A tool to assist GPs to conduct the ADF Post-discharge GP Health Assessment was developed by Flinders University in partnership with DVA. The tool brings together a number of widely available and well-validated screening measures in a single resource, covering the health domains required in the health assessment. A paper describing the development of the tool, including the criteria for the selection of screening measures, is currently in preparation.
The tool begins with a series of structured questions designed to collect information relating to the patient’s ADF service history and current social circumstances. The ADF history questions cover the years of service, veteran’s ADF field of work, number of deployments, whether the veteran had concussions or other head injuries, and whether the veteran has any health problems or injuries related to service. Social history includes questions related to marital status, number of children and current occupation. The main body of the tool comprises the health screening measures and items (Table 2).
Table 2. Main screening measures used in the ADF Post-discharge GP Health Assessment tool
|
| Health domain | Measure | Comment |
|---|
| Hearing |
Single question |
The question tests for difficulties with hearing loss or ringing in ears (tinnitus)4,5 |
| Pain |
Single question |
Single item relating to bodily pain from the RAND Corporation SF-366 |
| Sleep |
Single question |
Adaptation of a single item relating to sleep from the Post-traumatic stress disorder (PTSD) Checklist (PCL)7 |
| Psychological distress |
K10 |
The K10 comprises 10 questions about anxiety and depressive symptoms experienced in the past four weeks.8 In the veteran population, a score of 17 and above is considered positive for psychological distress and further assessment may be indicated |
| Post-traumatic stress disorder |
Primary Care PTSD |
The PC-PTSD is specifically designed to be used in the primary care settings and is included in the Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder9 |
| Level of physical activity |
Single question |
Single question derived from a brief physical activity screening tool used in Australian general practice10 |
| Sexual health |
Single question |
Adapted from a single item relating to sexual dysfunction11 |
| Anger |
Single question |
Single question from the US Post-deployment Health Assessment12 |
| Harm to self or others |
Two questions |
Two questions drawn from the Mental health advice book for practitioners: Helping veterans with common mental health problems13 |
| Alcohol |
Alcohol Use Disorders Identification Test-C |
The AUDIT-C is a three-item alcohol screen that can identify persons who are hazardous drinkers or have active alcohol use disorders.14 A score of four (men) or three (women) is considered positive for possible hazardous drinking |
| Substance use |
Four questions |
The questions are adapted from Smith15 and the Short Inventory of Problems – Alcohol and Drugs (SIP-AD) questionnaire, which asks about problems ever experienced in the participant’s lifetime related to alcohol or drug use16 |
| Smoking |
Two questions |
This question combines a commonly used item about smoking status and a binary no/yes question about interest in quitting |
A hard copy version of the health assessment tool is available from the DVA website (http://at-ease.dva.gov.au/professionals/clinical-resources/general-resources). The tool is also available through clinical record software Best Practice and Medical Director. Both software packages will include a field (in ‘Family and Social History’) to record a patient’s ADF service history. By checking the option for ‘past Australian Defence Force – Permanent or Reserves’, a preventive health notification will automatically be displayed in the actions/reminders area.
Best Practice and Medical Director have implemented the ADF Post-discharge Health Assessment through their letter writer templates. This allows information that was previously entered into the patient record to be included in the health assessment. This feature is designed to save time and avoid double entry of clinical information. For this reason, it is recommended that prior to administering the tool, the patient’s current health problems or medical conditions, as well as any medications, be reviewed. Where appropriate, this information should be updated in the patient’s electronic health record.
In 2016, both Best Practice and Medical Director will release customised assessment modules for the health assessment. One of the key advantages of the customised assessment modules is that they will automatically calculate a total score for each scale in the health assessment and provide an interpretation of the results. For example, the 10 items in the Kessler Psychological Distress Scale (K10) are automatically summed and if a score of 17 or more is produced, a message that this is considered positive for distress will be displayed.
The tool is accompanied by a comprehensive guide and a concise guide to provide the key actions and considerations for former ADF members who screen positive on one or more of the assessment items. By way of example, the suggested actions for a positive screen for medication misuse are shown in Box 1. The guides also contain contact details for the DVA, which provides veteran compensation, support and funding for healthcare treatment, and the Veterans and Veterans Families Counselling Service (VVCS).
Hard copy versions of the guides are available online (http://at-ease.dva.gov.au/professionals/clinical-resources/general-resources). When the customised assessment modules of the health assessment tool have been fully implemented, the guides will be accessible from Best Practice and Medical Director.
Box 1. Example of recommended actions to take following a positive screen for a medication problem
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What to do if a medication problem is detected
Engaging patients in a harm-reduction treatment program if medication misuse is detected is one recommended approach. Also consider establishing ground rules for future prescribing and involving other services in the treatment plan.
The Prescription Shopping Information Service (PSIS) is available to registered prescribers 24/7. It provides information on the prescription history of people whom the PSIS has identified as falling into a risk category, and is accurate up to the last 24 hours. Registered prescribers do not require patient consent to access this service, which is available on 1800 631 181.
If there are concerns about medication problems among DVA health card holders who obtain pharmaceuticals under the Repatriation Pharmaceutical Benefits Schedule (RPBS), contact the Veterans’ Affairs Pharmaceutical Advisory Centre (VAPAC) on 1800 552 580. |
Discussion
The ADF Post-discharge GP Health Assessment has the potential for early identification of health problems in the veteran patient population. The health assessment tool and accompanying guides provide detailed background information about health problems that veterans may experience. They are designed to enhance the capacity of general practice to manage these health problems. This includes advice on how to access veteran-specific services. The tool and accompanying guides are approved as Accepted Clinical Resources by the Royal Australian College of General Practitioners (RACGP) and endorsed by the Australian Primary Health Care Nurses Association (APNA).
Uptake of the health assessment, tool and guides in general practice will depend on many factors. The time taken to complete the assessment will obviously be a key consideration. Pilot testing of the tool indicates that the median time to complete the health assessment is around 38 minutes. However, this is dependent on the complexity of the veteran’s health needs. The time-based health assessment items on the MBS provide further reimbursement if additional time is required to provide these services.
A comprehensive evaluation of the impact of the health assessment (including the tool and guides) should be undertaken. This will demonstrate whether health problems that may have previously gone undetected are recognised in a timelier manner, and whether clinical management has improved. It is anticipated that increased awareness of veteran healthcare needs will facilitate better health outcomes for this population.
Authors
Richard L Reed MD, FRACGP, Head, Discipline of General Practice, Flinders University, Bedford Park, Adelaide, SA. richard.reed@flinders.edu.au
Stacey Masters MSc, Research Fellow, Discipline of General Practice, Flinders University, Bedford Park, Adelaide, SA
Leigh S Roeger PhD, Senior Research Fellow, Discipline of General Practice, Flinders University, Bedford Park, Adelaide, SA
Competing interests: The authors’ institution received a research grant from the DVA, which included payment for writing this manuscript and travel support for the authors.
Provenance and peer review: Commissioned, externally peer reviewed.