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Comprehensive Clinical Evaluation Program (CCEP) And Post-Deployment Health Clinical Practice Guideline (PDH CPG)
THE FAQ
What Is The CPG?
The Post-Deployment Health Evaluation and Management Clinical Practice Guideline, often referred to as the PDH CPG
or deployment health CPG, was designed to provide a systematic basis of care for patients in the military and VA
health care systems who have health concerns related to a deployment of any kind or at any time. It was developed
over a two-year period of time, taking advantage of lessons learned in evaluating and treating health concerns
presented by Gulf War Veterans along with basic advances in medicine, especially evidence-based medicine.
Why Was This CPG Developed?
Over the last decade the medical field learned many valuable lessons related to deployment health and the Comprehensive
Clinical Evaluation Program, or CCEP, was an instrumental part of that learning experience. Since the Gulf War, the
frequency of deployments and the nature of deployments has been continually changing. We have seen an increase in
the number of members deployed to military operations other than war and recently have seen domestic deployments
associated with the War on Terrorism. The problems that arise as a result of this diversity of venues and operations
would not lend themselves to a single formatted program of care. The DoD saw a need for a set of guidelines that
could address deployment related health concerns, regardless of when the soldier had been deployed. The best starting
place to develop such guidelines was to look at the experiences with the CCEP.
DoD asked the Institute of Medicine (IOM), a civilian organization that provides expert consultation on medical
practices, to conduct a review of the CCEP and make recommendations for improvement. That review, in conjunction
with advances in general medicine over the past 10 years, led to suggestions for improved practices for both evaluation
and treatment of health concerns post-deployment. The report and recommendations from the IOM was used as a
foundation in building the PDH CPG.
The Comprehensive Clinical Evaluation Program was designed in response to challenges in providing evaluation and
treatment of symptoms that were presented by veterans returning from the Gulf War. It used the best medical knowledge
at the time to provide a comprehensive evaluation process for complex symptoms presented by Gulf War veterans.
It has served a very valuable purpose in providing the best possible medical care to our Gulf War veterans for its time.
However, it was never really set up for any other deployments. In addition, the CCEP was developed as a system of
evaluation, not as a system to deliver follow-up care and management of a veteran's deployment related health concerns.
The PDH CPG took the best practices of the CCEP and enhanced them so long-term evaluation and management of deployment
health concerns could be delivered for veterans in a primary care setting.
Clinical practice guidelines are not restricted to just deployment health. In past years, there has been an increased
awareness of the need to base health care practices on the best medical research evidence that demonstrates the most
efficacy for a variety of common health concerns. We now have CPGs for numerous health problems ranging from diabetes
to tobacco use cessation. The deployment health CPG is another in this series. It uses the very best medical
information available to provide a foundation of information to guide the care for patients with deployment related
health concerns.
The CPG also takes into account the fact that medical knowledge grows and improves over time. So, a two-year review
process has been established. Every two years the practices used for deployment health will be reviewed and revised
to reflect new medical knowledge and practices. We have all seen government programs that were put into place with
good intentions but then take on a life of their own, continuing even when their usefulness no longer is realized.
It's hard to start a new program, but it's almost impossible to stop one. By having a required two-year review
process for the CPG, our deserving service members and their families will always have a continuously improving system
of care.
How Is The CPG Different From CCEP?
The CCEP used a process of intensive specialist evaluations to identify Gulf War health problems for treatment.
This practice had the advantage of using a "no stone unturned" method of evaluation. However, it also had many
disadvantages. It separated care for deployment related symptoms from other health care concerns the veteran may
have, creating a "fragmented" approach to health care. The CPG method moves health care back into an integrated
framework, by focusing care for all health concerns with the Primary Care Manager.
The clinical practice guideline was designed for implementation in Primary Care. It gives both the responsibility
for and comprehensive information about the patients total health picture to his or her doctor. In most cases,
types of symptoms and different illnesses are not mutually exclusive. For example, a robustly healthy person who
gets a cold presents a different medical picture than a person with asthma who gets a cold. Similarly, different
medications can conflict with each other. Recent medical knowledge supports the practice of integrating care. In
recent years, we have seen a shift in medical management for all health concerns, moving from a system of highly
fragmented specialty care back to a single source of medical management, similar to the family doctor in years past.
Because of this, patients have been seeing more of their health care concerns treated in primary care. That same
medical knowledge has been applied to deployment health. By centering all health care issues with one point of contact,
and with one health care provider having full knowledge of the whole person, care can be better integrated so that
parts of it don't fall through the cracks. The primary care provider will be provided with information and clinical
tools to effectively manage deployment specific issues in the primary care setting. Of course, specialty referrals
are still available, just as they always were. The difference is that all the medical information will come back to
the primary care provider for comprehensive health management, rather than going to a separate clinic or health care
information system. The patient and the primary care provider will collaborate to ensure that the patients presenting
concerns are addressed using the best medical evidence available, including specialty care evaluation and consultation.
Can I Still Use CCEP?
The CCEP is not going away. Eligible Gulf War veterans who wish a medical evaluation can still do so. By calling
the same toll-free hotline that the CCEP currently uses, veterans will continue to be able to schedule an evaluation.
While they will be encouraged to have the evaluation done using the new PDH CPG, they can still have the evaluation
done based on the previously used CCEP procedures. Those veterans who are currently enrolled in the CCEP and are
undergoing evaluation can complete the process. They will be given the option of continuing in the program as it
stands or choosing to receive care for their health concerns according to the guidance provided in the PDH CPG at
the primary care or family practice clinic of their local MTF. In some cases, their symptoms no longer persist and
those patients may simply choose not to continue in care at this time. They will always be welcomed later by their
primary care provider should symptoms recur or new problems arise which they feel are related to either the Gulf War
or any other deployment.
Does The CPG Have A Registry?
The "Gulf War registry" involved a toll-free number that individual service members called to enter the CCEP
program. It was helpful at the time to have a centralized source of information about the numbers and the kinds of
problems experienced by members who had Gulf War symptoms and to track their care through the CCEP program. However,
the responsibility was given to the individual patient to know that there was such a number, to find out the number,
and to take the time to call the number to get their name on the list for an evaluation. In the past decade,
information technology has advanced tremendously. We now have electronic medical records and advanced medical
information systems. We no longer need to place the responsibility for identifying health problems on the patient.
The CPG has given that responsibility back to the health care system. The initial step in the CPG is for clinic staff
to ask each and every patient that presents to any military primary care or family practice oriented clinic with a
health concern a simple question: "Is the health concern that brings you to the clinic today related to a deployment?"
If the patient responds, "yes," then that response is coded using a diagnostic code specifically created to designate
a deployment-related visit (ICD-9, V70.5__6) in the health information system along with an additional diagnosis and
related code to correspond with the specific concern being identified. In this way, an electronic "registry" of sorts
is created, but without the patient having to take any special action. The information is maintained in the patient's
medical record and will remain there for future follow-up.
This new method of tracking deployment-related concerns does not mean that the Gulf War CCEP database is going away.
On the contrary, Gulf War veterans who experience a concern and have not had the opportunity to enter into the CCEP
can still do so. Many veterans have appreciated having this service available to them and it will continue to be
available, even as we transition to the new PDH CPG. Veterans may call the same toll-free number that has been
associated with the CCEP in the past to request a comprehensive evaluation of their health concerns associated with
their Gulf War service. As an alternative, they can report their problem as deployment-related and associated with
Gulf War service through their primary care clinic as part of the deployment health guideline system of care. Either
way, their concerns will be documented in the medical information system. Those who are currently enrolled in the
CCEP and have evaluations pending, but wish to transition to the new CPG system of care through their primary care
clinic are also encouraged to call the toll-free number to indicate that transition decision.
Will We Still Be Doing Phase I And Phase II Evaluations?
Phase I and Phase II were terms used in the CCEP program to indicate levels or steps of intensity in evaluation of the
patient's symptoms. Phase II evaluations were generally conducted in a CCEP-designated specialty clinic. The CPG
prescribes care in the primary care clinic. However, since problems vary in complexity and intensity, a stepped-level
of care, similar to what we have come to know as the "Phase" approach in CCEP, has been built into the recommended
process of care in the clinical practice guideline. There are basically four steps or four types of deployment-related
concern that receive attention appropriate to the symptoms presented.
Level 1:
Patients who have a definitive diagnosis associated with a prior deployment. An example would be poison ivy or a
sprained ankle that occurred while the service member was deployed but persists even after they return. These problems
are easily diagnosed and are treated just as they would be based on the diagnosis.
Level 2:
Patients with deployment health-related questions. Some patients don't currently have any symptoms and may, in fact,
have not been deployed. But, they have questions or need health information related to concerns they may have about a
past or future deployment. They come to the primary care clinic with questions for the provider about those issues.
For example, they may have concerns about potential anthrax exposure or issues associated with an on-going health problem
and how that might be affected by a deployment. They will receive the information they need from the provider or
other clinic patient education provider. If the provider does not have all the information readily available, or
doesn't have the time to review the information during a standard appointment timeframe, they may arrange for a longer
30-minute appointment time for follow-up to ensure the patient has the information they need to satisfactorily answer
their questions. This follow-up appointment time has been built into the guideline to allow for effective clinical
communication and patient education.
Level 3:
Some patients may come to the primary care clinic with symptoms following a deployment that simply don't fit into a
clear-cut medical diagnosis. We sometimes refer to these symptoms as medically unexplained physical symptoms or MUPS.
For these patients, information and education are generally important, along with appropriate medical tests.
The primary care provider again has the option to arrange for a longer appointment time for follow-up to discuss the
tests, their results, and/or other associated health questions and concerns. In addition to the standard specialty
consults at their local or regional MTF, they also have access to clinical experience at the DoD Deployment Health
Clinical Center or DHCC. DHCC provides web-based information, education, and training for clinicians as well as patient
education materials. In addition, the Department of Defense has established this Center to provide support to
clinicians in the management of these complex situations. Providers can consult the DHCC clinicians with questions
they have specific to the evaluation and treatment of medically unexplained physical symptoms related to deployments.
Level 4:
There are times, although relatively few, when medically unexplained physical symptoms turn into chronic and even
disabling conditions. These conditions create significant distress for the patient and sometimes also for the patient's
family. The quality of life of the patient tends to suffer. Consultation with a multi-disciplinary health care team
is generally indicated in these cases, as is laid out in the CPG. Specialty referral care through the local and/or
regional MTF is generally sought, even though overall health management, including information from that specialty
care, still comes back to the primary care provider. However, even the best of medical care isn't always effective
in meeting the needs of every individual. For patients who don't respond to available medical treatment through their
local or regional MTF, referral tertiary care, organized around a rehabilitative model, is available at the DHCC
Specialized Care Program. The primary care provider can contact the DHCC at the toll-free number to discuss the
services available and the process of referral to the specialized care program.
Who Provides Guidance On How The CCEP and CPG Program Function?
The Office of the Secretary of Defense, Deputy Assistant Secretary of Defense for Health Affairs provides guidance on
all health care programs including these. They provide this guidance through coordination with the Service Surgeon
Generals. See CCEP Policy Statements.
Who Can I Call If I Have More Questions or Comments About The CPG or The CCEP?
The DoD Deployment Health Clinical Center, DHCC, will be assuming responsibility for the CCEP hotline, effective
1 February 2002. DHCC is also the identified clinical support center for the post-deployment health clinical practice
guideline. You can call either of the toll-free numbers with your questions and comments or if you need help navigating
through the transition period. Additional information is also available on the website
through www.pdhealth.mil. Those toll-free numbers are:
DOD-CCEP 1-800-796-9699
VA-CCEP 1-800-749-8387
Email: pdhealth@na.amedd.army.mil
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