Joe McBreen CAPT, MC, USN Developmental Pediatrician EDIS Medical Consultant Naval Hospital Camp Lejeune, NC, 28547 Emai

1. 1

2. An assignment program Interfaces with military and civilian agencies to support Aims to ensure optimum use of PCS money considering: Navy�s requirements SMs� career EFM needs It will not: Ruin careers Prevent deployment Non-enrollment can hinder: Career Mission effectiveness Cost avoidance 2

3. 3 DODINST 1342.12 DODINST 1315.19, Authorizing Special Needs Family Members Travel Overseas at Government Expense, April 11, 2005 ENCLOSURE 4: DoD Criteria for ID a EFMs E4.1. Special Medical Needs E4.1.1.1. Conditions requiring f/u > 1/yr or specialty care. E4.1.1.2. MH, Inpt in last 5yr or, >1 visit/mo for > 6m). E4.1.1.3. Asthma or other respiratory-related diagnosis E4.1.1.4. ADD/ADHD E4.1.1.5. Adaptive equipment. E4.1.1.6. Assistive technology. E4.1.1.7. Environmental/architectural considerations.

4. 4 Navy Marine Corps Insts SECNAV Instruction�1754.5B (14 Dec 05), Exceptional Family Member Program OPNAVINST 1754.2C (22 Jan 2007), Exceptional Family Member Program BUMEDINST 1300.2A (8 Aug 2000), Medical, Dental, and Educational Suitability Screening and Exceptional Family Member Program Enrollment w/Change Transmittal 1 MCO P1754.4B (20 Sep 2010), Exceptional Family Member Program

5. Who is Eligible? Family Member of: ACDU or Mobilized Reservist Enrolled in DEERS. Diagnosed with a chronic medical, dental, behavioral or educational condition that requires special services. Residing with the active duty sponsor (except geo bachelor or family member living in a structured care facility). 5

6. Navy EFMP Organization 6

7. 7

8. 8

9. 9 MEDICAL: Chronic medical issues. Most chronic health care conditions: e.g. asthma, autism, DM, MS, complicated pregnancy, prematurity Some conditions which may not need to be enrolled: e.g. mild allergic rhinitis, uncomplicated recurrent OM, mild eczema MENTAL HEALTH: Chronic mental health conditions. Depression, Anxiety, PTSD, Bipolar Disorder, ADHD No enrollment required for temperamental differences, behavioral insomnia

10. 10 DENTAL: Significant chronic dental issues Ongoing care by subspecialist Oral surgery directed reconstructions Orthodontics if medically indicated (e.g. genetic Sro) No enrollment for typical caries, braces w/o craniofacial issues EDUCATIONAL: Significant ongoing educational issues Issues which have required a 504 plan, ISP, IFSP or IEP LD, ID, CP. Typically a concomitant medical condition.

11. 11 ECHO: Extended Care Health Options Enrollment in EFMP required for participation ABA, DME, Respite Care HUMS: Humanitarian Reassignment EFMP enrollment will help insure that the family is transferred to a new duty station that can meet the medical and education needs of all family members OSS: Overseas screening: required for OCONUS PCS EFMP enrollment insures that detailers will know about conditions which may preclude OCONUS orders as early as possible, avoiding unfortunate scrambles for orders, unaccompanied orders, etc.

12. 12

13. 13 What EFMP Enrollment MAY Do For You... MAY give preferential status for on-base housing. MAY decrease number of moves. MAY help you find local resources. MAY help with humanitarian reassignments.

14. 14 What EFMP Enrollment WON�T Do For (or To) You... WON�T prevent overseas or unaccompanied tours. WON�T make you ineligible for sea duty. WON�T get you to your billet of choice. WON�T decrease promotability. WON�T be seen by anyone but you, your CO, or detailer.

15. Mil Med. 1994 Jun;159 (6): 449-53 The Exceptional Family Member Program: views of unit leaders. Unit leaders perceived the Army EFMP positively, considered the program beneficial to the Army, the soldiers, and their families. considered the EFMP soldiers: To be well accepted in their units Performance comparable to non-EFMP soldiers. 15

16. Mil Med. 1995 Dec;160 (12): 639-43 The exceptional family member program: perceptions of active duty enrollees. Fifty-four soldiers who had a family member enrolled in the Army EFMP: satisfaction with treatment of the EFM perceived the EFMP positively their units were supportive of them no significant obstacles to career advancement. 16

17. National Defense Authorization Act 2010 �Provide military families with special needs with information on the services, support, and assistance available through the Department of Defense regarding such members with special needs, including information on enrollment in programs of the military departments for such services, support and assistance�requirements for resources (including staffing) to ensure the availability through the DoD of appropriate numbers of case managers to provide the individualized support for military families with special needs.� 17

18. Factoids Navy: Approx 1,960 EFMs w autism; approx 7% of total. ASD and related conditions, have increased needs. NDAA mandated guidelines and family support. Establish Office of Community Support for Military Families with Special Needs. Mandates family case management. 32 case liaisons in place at FFSCs. Navy investigating case management system. Navy, Army, USMC and Air Force meet on a regular basis to discuss joint solutions for all military EFMs. Each Service implements DoDI 1342.12 and NDAA differently. Same Goal: ensure every EFM has the services needed no matter what their geographic location and to connect them with resources no matter what the destination. 18

19. 19 EFM Categories: Navy CAT 1 For monitoring purposes only CAT 2 Limited overseas locations CAT 3 No overseas assignments CAT 4 Assignments near major medical locations facilities CAT 5 Homesteading program CAT 6 Temporary category (6-12 MONTHS)

20. 20

21. Homesteading Locations Considered if EFMs needs are: - highly specialized and complex, or - severe requiring continuity of care Possible Locations: Norfolk, VA Jacksonville, FL San Diego, CA Bremerton, WA Washington, DC

22. 22 Your Role As A PCM Be aware of the EFMP mandate. Identify patients that MAY meet criteria for enrollment. Inform the family of the DoD and Service requirement Complete the Medical portion of the application.

23. 23 Challenges with EFMP Paperwork Patient you�ve never met Challenging, unfair to family and provider Staff should try to schedule EFMP visits with the PCM Deployments, urgent need, planning ahead can help If unavoidable, (1) check AHLTA, (2) talk to family present, (3) ask about Network care Time�. 15 to 30 minutes to complete the EFMP application Pre-made EFMP templates Front office staff assistance, if trained Have patients return for an additional visit Patient safety impacted by incomplete/incorrect information

24. 24 10 year old male, living with family in Jacksonville Dx�ed with ADHD and mild language based LD at 7 yr/o Now in 4th grade and has a 504 plan for basic accommodations. His academics are at grade level, grades are A�s, B�s and C�s. No significant behavioral problems, no ongoing care from a psychologist and has been managed only by his pediatrician with basic behavioral strategies and Concerta 18 mg.

25. 25 The educational and medical services he requires can be provided by his pediatrician His condition is very unlikely to require specialty care or a hospitalization at a specialty center He is assigned Category 2, which means his family may be able to go overseas, can live anywhere in U.S. CAT 2 allows for ongoing monitoring of a chronic condition, while requiring detailers to always consider his medical and education needs when evaluating duty stations Updated packet every 3 years, category can change, disenrollment possible

26. 26 Example - CAT 3: Unstable SZ 29 year old adult with longstanding stable Sz D/O, sees neurologist 3-4 times per year, has required a hospitalization 2 years ago and medications have been changed twice in last 3 years, due to side effects and breakthrough seizures Assigned CAT 3 as neurology not typically available at Navy OCONUS Sites and severe seizure could result in hospitalization, ICU stay Again reevaluate every 3 years

27. 27 Example - CAT 4: Severe RA 38 yr/o dependent spouse with severe RA Diagnosed about 10 years ago, stable But�requires multiple medications, including a monthly infusion of remicade Specialty care with rheumatology and physiatry. Has seen pain clinic last year. Needs to be near major med cen for: Subspecialty care with infusion center Needs to be near an intensive care unit

28. 28 2 yr/o male, living in Naples, Italy Parents are worried about his development Concerns about language, social skills and repetitive movements �Doesn�t seem to be with us,� �likes� to play alone, repetitive movements of hands, prefers to play with parts of toys, does not request, only uses 3 words, repeats words, limited eye contact Motor developmental is typical, healthy boy is �never sick�

29. 29 Examples - Screening Failure 2 yr/o with Hx of extreme prematurity (25 WGA) Born in civilian NICU, no major MTF, had complications. ROP, CLD, IVH, devo delay, feeding difficulties Followed by peds GI, ophtho, devo, SLP and OT Parents had opportunity to take position in small country with limited medical resources, no children�s hospital Never enrolled in EFMP, doctor who completed overseas screening was not privy to medical records

30. 30 RSV pneumonia during first winter, required mechanical ventilation, no PICU available. Transferred to major medical center. Recovered, but may have been preventable. Early return, due to failure of overseas screening Cost - $22,000-$28,000 to move a family of four overseas Stressful move home for family, siblings change schools again, home sold, moved to grandparents. Father completed unaccompanied tour. Investigation initiated by command, potentially career damaging

31. Naval Medical Center Portsmouth (EAST) Chair � CDR Akins Naval Medical Center, San Diego (WEST) Chair � CAPT King Naval Hospital Yokosuka (Pacific Rim) Chair � LCDR Foster 31

32. NMW CSC Applications per year ~ 1500/yr New ~ 1000/yr Child : Adult ratio ~ 3:4 Expedite:Routine ratio ~ 1:10 CAT 0 ~ 2% CAT 1 ~ 1% CAT 2 ~ 15% CAT 3 ~ 20% CAT 4 ~ 35% CAT 5 ~ 30% CAT 6 ~ 3% 32

33. 33 NMW CSC Applications per year ~ 1500/yr Disenrollments ~ 5% Processing time by CSC ~ 7 days Increasing trends Total numbers % children higher categories

34. Questions ? 34

35. EFMP Completing DD Form 2792 2792-1 35

36. New Forms: 1 Instructions: smaller print Privacy Statement is expanded and has web links Demographics: Purpose of the form: check boxes and writing space Branch of Service: check boxes Administrative Use Only: now a full page Patient Status: Temporary conditions: 3 spaces and writing space Diagnosis: 7 5 spaces Full page for Prognosis, Treatment Plan and CA/Additional Information with writing space 36

37. New forms: 2 Required Care: Additional Providers on the check list: Cleft palate team Pediatric Nurse Practitioner Psychiatric Nurse Practitioner Environmental / Architectural Considerations More check boxes, more writing space Adaptive Equipment / Special Medical Equipment More check boxes, more writing space 37

38. New forms: 3 Addendum 1: Asthma Addendum 2: Mental Health More check boxes, and still plenty of writing space Addendum 3: Autism NEW !!! Special Education / Early Intervention Summary Expanded Privacy Statement with web links More check boxes 38

39. 39 Filling out the Application:Legibility

40. 40 Filling out the Application:Legibility

41. 41 Filling out the Application: Attention to Detail �MINIMUM HEALTH CARE SPECIALTY REQUIRED FOR CARE� health care required. � Need versus availability Does asthma require a pulmonologist? Does ADHD require a psychiatrist? Does hypothyroidism require an endocrinologist?

42. 42 Filling out the Application: Attention to Detail Durable Medical Equipment can be hard to obtain in some places�. Hearing aides Braces, orthotics, wheelchairs PLEASE write comments!

43. 43 Filling out the Application: Attention to Detail Addendum A-1 (Asthma / RAD Summary) Date medication last used � helps differentiate what patient is currently on, and what they have been on (and how long they�ve been off a medication)

44. 44 Filling out the Application: Attention to Detail Don�t forget ICD code! Age at diagnosis helps determine chronicity.

45. 45 Filling out the Application: Attention to Detail

46. 46 Filling out the Application: Attention to Detail

47. 47 Filling out the Application: Attention to Detail Authorized providers: NOT authorized providers: MD Psychologist PA Social Worker NP

48. 48 ADHD: CAT 2 Category 2 (Pinpoint CONUS and Overseas) Stable, single dose medication, manageable by pediatrician or FP. Responding well to treatment - medication and/or IEP. No counseling issues. No behavioral problems.

49. 49 ADHD: CAT 3 Category 3 (No Overseas) Less stable on medication: Using higher doses, or requiring less common medications. Behavior problems. Counseling mandatory: discontinuation of services would be detrimental.

50. 50 ADHD: CAT 4 Category 4 (Major Medical Center) Rare Children with significant behavioral or associated problems requiring the care of a subspecialist and/or uncommon medications.

51. 51 How You Can Help Ensure that the medication section is completed in detail. Ensure that the �number of visits� section is completed. Use descriptive details in the comments section regarding behaviors, family coping, etc.

52. 52 Asthma: CAT 2 Category 2 (Pinpoint CONUS and Overseas) Infrequent use of medications. �Maintenance� medications with few exacerbations. No hospitalizations within the past year or more. No subspecialty care.

53. 53 Asthma: CAT 3 Category 3 (No Overseas) Chronic use of several medications. Frequent visits to MD, but still managed by generalist. Few hospitalizations in past, no ICU admissions.

54. 54 Asthma: CAT 4 Category 4 (Major Medical Center) Chronic use of multiple medications. Frequent visits to MD, including subspecialist. Several hospitalizations in past. ICU admission.

55. 55 Developmental Delay: CAT 2 Category 2 (Pinpoint CONUS and Overseas) All EDIS sites should be able to provide therapy services for these children. Children with basic therapy needs.

56. 56 Developmental Delay: CAT 3 Category 3 (No Overseas) Children with more significant medical needs associated with their delays. Chronic health issues. Vision or hearing impaired. Severe delays, possible autism or cerebral palsy.

57. 57 Developmental Delay: CAT 4 Category 4 (Major Medical Center) Those children with significant medical problems or profound delays, requiring subspecialty care.

58. 58 Developmental Delay: CAT 6 Category 6 (Temporary) Used with NICU graduates, whose developmental course has not yet been determined, but are at high risk for developmental and medical problems. Used for children where work-up is still �in progress�.

59. Questions ? 59