1 CLINICAL PREVENTIVE SERVICES (CPS) CAPT CHICKY MCKINZIE, NC, USN AMSUS NOV 2006.

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CLINICAL PREVENTIVE CLINICAL PREVENTIVE SERVICES (CPS)SERVICES (CPS)

CAPT CHICKY MCKINZIE, NC, USNCAPT CHICKY MCKINZIE, NC, USN

AMSUS AMSUS

NOV 2006NOV 2006

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ObjectivesObjectives Discuss the age/gender specific Discuss the age/gender specific

recommnedations for CPS based on recommnedations for CPS based on the findings from United States the findings from United States Preventive Services Task Force Preventive Services Task Force (USPSTF).(USPSTF).

Identify risk factors to be discussed Identify risk factors to be discussed during PHA face-to-face prevention during PHA face-to-face prevention counseling session.counseling session.

Determine documentation required on Determine documentation required on forms DD2766 and NAVMED 6120/5. forms DD2766 and NAVMED 6120/5.

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Clinical Preventive Services (CPS) Clinical Preventive Services (CPS) “THE KEY TO A FIT AND HEALTHY “THE KEY TO A FIT AND HEALTHY

FORCE!”FORCE!”

Prevention works!Prevention works!

Everyone needs CPS!Everyone needs CPS!

Behavior is important -- Behavior is important -- individuals must be responsible!individuals must be responsible!

Health Care Team are a valuable Health Care Team are a valuable resource!resource!

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CPS RequirementsCPS Requirements A nurse or credentialed provider A nurse or credentialed provider

(MD/DO, FNP, PA, AC/IDC) will (MD/DO, FNP, PA, AC/IDC) will complete a face-to-face individualized complete a face-to-face individualized review of medical status with review of medical status with member:member:

AgeAge GenderGender OccupationOccupation Family historyFamily history Deployment historyDeployment history Behavioral risk factorsBehavioral risk factors

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CPS RequirementsCPS Requirements

Members will be provided age/gender Members will be provided age/gender specific CPS recommendations based on specific CPS recommendations based on USPSTF as approved by DoD Health USPSTF as approved by DoD Health Affairs.Affairs.

Available at:Available at:– ww.preventiveservices.ahrq.govww.preventiveservices.ahrq.gov– Call 1-800-358-9295 for a free copy of: Call 1-800-358-9295 for a free copy of:

“ “The Guide to Clinical Preventive Services”The Guide to Clinical Preventive Services”

http://www.ahrq.gov/clinic/pocketgd.pdfhttp://www.ahrq.gov/clinic/pocketgd.pdf

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USPSTF GRADINGUSPSTF GRADING

A. Strongly recommends to provide the A. Strongly recommends to provide the service to eligible patients.service to eligible patients.

B. Recommends to provide the service to B. Recommends to provide the service to eligible patients.eligible patients.

C. Makes no recommendation for or C. Makes no recommendation for or against against routine provision of the service.routine provision of the service.

D. Recommends against routinely D. Recommends against routinely providing providing the service to the service to asymptomatic patients.asymptomatic patients.

I. Concludes that the evidence is I. Concludes that the evidence is insufficient to recommend for or insufficient to recommend for or against routinely providing the against routinely providing the

service.service.

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CPS RequirementsCPS Requirements

Screen Screen Medical record for risk factors. Medical record for risk factors.

VerifyVerify Completion of past medical referrals.Completion of past medical referrals.

ReferRefer Medical conditions for follow-up, to Medical conditions for follow-up, to

civilian PCM for CPS and treatment civilian PCM for CPS and treatment unless the condition is service related.unless the condition is service related.

(CPS are recommendations only. IMR elements (CPS are recommendations only. IMR elements are medical readiness requirements.)are medical readiness requirements.)

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CLINICAL PREVENTIVE CLINICAL PREVENTIVE SERVICES (CPS)SERVICES (CPS)

Even though CPS are Even though CPS are highly recommended,highly recommended,

it is important to note it is important to note that these screening that these screening

exams can save exams can save lives!!!lives!!!

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Problem-Focused Physical Problem-Focused Physical ExamExam

If a member identifies a If a member identifies a specific health issue during specific health issue during

the PHA, a credentialed the PHA, a credentialed provider will conduct a provider will conduct a

problem-focused physical problem-focused physical examination and provide examination and provide

follow-on care follow-on care recommendations.recommendations.

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TOOLS ARE NEEDEDTOOLS ARE NEEDEDFOR CPS DOCUMENTATIONFOR CPS DOCUMENTATION

DD2766DD2766

NAVMED NAVMED

6120/56120/5

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DD2766 Screening Exams DD2766 Screening Exams DocumentationDocumentation

* = Actual result* = Actual result N = NormalN = Normal X = AbnormalX = Abnormal E = Done E = Done

elsewhereelsewhere

R = RefusedR = Refused NA = Not indicatedNA = Not indicated COMP = CompletedCOMP = Completed INCOMP = INCOMP =

IncompleteIncomplete

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Screening Exams – Screening Exams – Section 7 of DD2766Section 7 of DD2766

Guidance is available at:Guidance is available at: httphttp://www-nehc.med.navy.mil/hp/cps/pha.htm://www-nehc.med.navy.mil/hp/cps/pha.htm

PHA (1)PHA (1)

*Weight (2)*Weight (2)

*Height (3) *Height (3)

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Screening for ObesityScreening for Obesity

Assessment of overweight and obesity Assessment of overweight and obesity involves using three key measures:involves using three key measures:

Body Mass Index (BMI = kg/m2)Body Mass Index (BMI = kg/m2) - describes relative - describes relative weight for height, is significantly correlated with weight for height, is significantly correlated with total body fat - overweight is BMI 25-29.9, obese is total body fat - overweight is BMI 25-29.9, obese is BMI 30 or overBMI 30 or over

Waist circumference - > 35” women and > 40” for Waist circumference - > 35” women and > 40” for men men

Risk Factors - traits and lifestyle habits that Risk Factors - traits and lifestyle habits that increase the risk of diseases associated with obesityincrease the risk of diseases associated with obesity

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Screening for High Blood Screening for High Blood Pressure- *Blood Pressure Pressure- *Blood Pressure

(4)(4) Screen adults aged 18 Screen adults aged 18

and older for high and older for high blood pressureblood pressure (HBP) (HBP)

HBP is defined as a HBP is defined as a systolic BP of 140 mm systolic BP of 140 mm Hg or higher, or a Hg or higher, or a diastolic BP of 90 mm diastolic BP of 90 mm Hg or higherHg or higher

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Screening for Lipid Screening for Lipid Disorders *Cholesterol (5)Disorders *Cholesterol (5)

Age Age

>>Men 35 years Men 35 years older older WWomen aged 45 omen aged 45 years years olderolder

Assess for increased Assess for increased risk of coronary heart risk of coronary heart diseasedisease

Every 5 years unless Every 5 years unless lipid levels arelipid levels are close close to warranting therapyto warranting therapy

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*Cholesterol (5)*Cholesterol (5) Screen younger adults (men aged 20 Screen younger adults (men aged 20

to 35 and women aged 20 to 45) for to 35 and women aged 20 to 45) for lipid disorders if they have other risk lipid disorders if they have other risk factors for coronary heart disease.factors for coronary heart disease.

– DiabetesDiabetes

– Family hx of CVD before age 50 in Family hx of CVD before age 50 in male relatives or age 60 in female male relatives or age 60 in female relativesrelatives

– Family hx suggestive of familial Family hx suggestive of familial hyperlipidemiahyperlipidemia

– Multiple CHD risk factors (Tobacco Multiple CHD risk factors (Tobacco Use, HTN)Use, HTN)

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*Cholesterol (5)*Cholesterol (5)

CholesterolCholesterol: (recommended screening) : (recommended screening) Desirable= 200 mg/dl or lessDesirable= 200 mg/dl or less

LDLLDL::Desirable= 70-160mg/dl – depends Desirable= 70-160mg/dl – depends

on risk on risk factorsfactors(Less than 100 is optimal)(Less than 100 is optimal)

HDLHDL: (recommended screening): (recommended screening)Desirable = >40 mg/dl (males) Desirable = >40 mg/dl (males)

>50 mg/dl (females)>50 mg/dl (females) TriglyceridesTriglycerides::

Desirable = Below 150 mg/dl or lessDesirable = Below 150 mg/dl or less

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Screening for Screening for Coronary Heart DiseaseCoronary Heart Disease

Recommends against routine Recommends against routine screening with resting screening with resting electrocardiography (ECG). electrocardiography (ECG).

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Screening for Screening for Type 2 Diabetes MellitusType 2 Diabetes Mellitus

Recommends screening in adults Recommends screening in adults

with hypertension or hyperlididemia.with hypertension or hyperlididemia.

Fasting plasma glucose (FPG) every 3 Fasting plasma glucose (FPG) every 3 years with shorter intervals in high-risk years with shorter intervals in high-risk personspersons

(Evidence is insufficient to recommend for (Evidence is insufficient to recommend for or against routinely screening or against routinely screening

asymptomatic adults for Type 2 diabetes.)asymptomatic adults for Type 2 diabetes.)

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Screening for Hearing Screening for Hearing Impairment - Hearing (6)Impairment - Hearing (6)

Audiometric test may be ordered for Audiometric test may be ordered for occupational exposure to noise or occupational exposure to noise or reported hearing loss by memberreported hearing loss by member

(Given the availability of new evidence, the (Given the availability of new evidence, the USPSTF has decided to update its 1996 USPSTF has decided to update its 1996

recommendation. This work is currently in recommendation. This work is currently in progress.)progress.)

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Screening for Skin Cancer Screening for Skin Cancer

Skin Exam (7)Skin Exam (7)

Using a total-body skin examination for the Using a total-body skin examination for the early detection of cutaneous melanoma, early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin basal cell cancer, or squamous cell skin cancer. At substantially increased risk are: cancer. At substantially increased risk are:

– Persons with atypical molesPersons with atypical moles

– Those with >50 molesThose with >50 moles

(Evidence is insufficient to recommend for or against (Evidence is insufficient to recommend for or against routine screening for skin cancer.routine screening for skin cancer.))

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Screening for Oral Cancer Screening for Oral Cancer Oral/Dental (8)Oral/Dental (8)

Even though there is insufficient Even though there is insufficient evidence for screening for or evidence for screening for or

against against Oral Cancer, the Oral Cancer, the dentist chair is a “teachable dentist chair is a “teachable

moment” regarding moment” regarding prevention!!!!prevention!!!!

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Screening for Visual Screening for Visual Impairment - Eye/Vision Impairment - Eye/Vision

(9)(9) Insufficient evidence to Insufficient evidence to

recommend for or against recommend for or against screening adults for glaucoma. screening adults for glaucoma.

Insufficient evidence to Insufficient evidence to recommend for or against recommend for or against screening for diminished visual screening for diminished visual acuity in asymptomatic adults.acuity in asymptomatic adults.

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Screening for Breast Screening for Breast CancerCancer

Breast Exam (10)Breast Exam (10) Evidence is insufficient to recommend Evidence is insufficient to recommend

for or against routine clinical breast for or against routine clinical breast exam (CBE) alone to screen for breast exam (CBE) alone to screen for breast cancer.cancer.

Evidence is insufficient to recommend Evidence is insufficient to recommend for or against teaching or performing for or against teaching or performing routine breast self-examination (BSE).routine breast self-examination (BSE).

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Screening for Breast Screening for Breast Cancer Mammogram (11)Cancer Mammogram (11)

Recommends screening Recommends screening mammography, with or without mammography, with or without clinical breast examination clinical breast examination (CBE), every 1-2 years for (CBE), every 1-2 years for women aged 40 and older.women aged 40 and older.

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Screening for Cervical Screening for Cervical Cancer PAP (12)Cancer PAP (12)

Strongly recommends screening Strongly recommends screening for cervical cancer in women who for cervical cancer in women who have been sexually active and have been sexually active and have a cervixhave a cervix..

– Pap smear screening within 3 Pap smear screening within 3 years of onset of sexual activity years of onset of sexual activity or age 21or age 21

– At least every 3 yearsAt least every 3 years

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PAP (12)PAP (12) Recommends against routine Pap Recommends against routine Pap

smear screening in women who have smear screening in women who have had a total hysterectomy for benign had a total hysterectomy for benign disease. disease.

Evidence is insufficient to recommend Evidence is insufficient to recommend for or against:for or against:

– The routine use of The routine use of human papillomavirushuman papillomavirus (HPV) testing as a primary screening test (HPV) testing as a primary screening test for cervical cancer. for cervical cancer.

– The routine use of new technologies to The routine use of new technologies to screen for cervical cancer. screen for cervical cancer.

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Screening for Chlamydial Screening for Chlamydial InfectionInfection

Strongly recommends:Strongly recommends:Screening for chlamydial infection in Screening for chlamydial infection in

all sexually active women aged 25 all sexually active women aged 25 years years and younger, and other and younger, and other asymptomatic asymptomatic women at increased women at increased risk for infection.risk for infection.

(Evidence is insufficient to recommend (Evidence is insufficient to recommend for or against routinely screening for or against routinely screening asymptomatic men for chlamydial asymptomatic men for chlamydial

infection.)infection.)

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Screening for Colorectal Screening for Colorectal Cancer Cancer

Fecal Occult Blood (13), Fecal Occult Blood (13), Sigmoid (14), Colonoscopy Sigmoid (14), Colonoscopy

(15)(15) Strongly recommends that clinicians screen Strongly recommends that clinicians screen men and women 50 years of age or older men and women 50 years of age or older for colorectal cancer. Potential screening for colorectal cancer. Potential screening options determined by PCM: options determined by PCM:

– Fecal occult blood testing (FOBT) Fecal occult blood testing (FOBT) annually, orannually, or

– Flexible sigmoidoscopy and double-Flexible sigmoidoscopy and double-contrast barium enema every 5 years, orcontrast barium enema every 5 years, or

– Colonoscopy every 10 years Colonoscopy every 10 years – Persons at higher risk initiate screening Persons at higher risk initiate screening

at an earlier ageat an earlier age

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Screening for Testicular Screening for Testicular Cancer - Testicular (16)Cancer - Testicular (16)

Recommends against routine Recommends against routine screening for testicular cancer screening for testicular cancer

in asymptomatic adolescent in asymptomatic adolescent and adult males.and adult males.

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Screening for Prostate Screening for Prostate Cancer - Prostate (17Cancer - Prostate (17))

Men aged 50-70 at average risk and Men aged 50-70 at average risk and men over 45 at increased risk are men over 45 at increased risk are most likely to benefit from screeningmost likely to benefit from screening

(Evidence is insufficient to recommend for (Evidence is insufficient to recommend for or against routine screening for prostate or against routine screening for prostate

cancer using prostate specific antigen cancer using prostate specific antigen (PSA) testing or digital rectal examination (PSA) testing or digital rectal examination

(DRE).)(DRE).)

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Rubella Screen (18)Rubella Screen (18)

Screening for rubella:Screening for rubella:– Women of childbearing age Women of childbearing age – Susceptible nonpregnant women Susceptible nonpregnant women – Susceptible pregnant women should be Susceptible pregnant women should be

vaccinated in the immediate postpartum vaccinated in the immediate postpartum period period

– Screen female members for evidence of MMR Screen female members for evidence of MMR vaccine or rubella antibody titer (one time vaccine or rubella antibody titer (one time requirement)requirement)

(Given the availability of new evidence, the USPSTF has (Given the availability of new evidence, the USPSTF has decided to update its 1996 recommendation. The 1996 decided to update its 1996 recommendation. The 1996 recommendation may contain information that is out of recommendation may contain information that is out of

date.)date.)

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Occupational Screening Occupational Screening Exams (19)Exams (19)

Document occupational exposuresDocument occupational exposures

Refer to Occupational Medicine or OSHA Refer to Occupational Medicine or OSHA Program Manager to ensure member is up Program Manager to ensure member is up to date with job-specific requirementsto date with job-specific requirements

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(20), (21), (22), (23), (24), (20), (21), (22), (23), (24), (25)(25)

Enter other screening Enter other screening tests deemed tests deemed appropriateappropriate

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Health CounselingHealth Counseling

Biggest bang for the buck!Biggest bang for the buck! Seize the teachable moment!Seize the teachable moment! Use your support staff to Use your support staff to

reinforce messages!reinforce messages! Track on DD2766/Counseling Track on DD2766/Counseling

+ change = healthier people+ change = healthier people

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DD2766 DD2766 Section 5 CounselingSection 5 CounselingHealth Promotion/CPSHealth Promotion/CPS

Target individually identified risk factors Target individually identified risk factors and behaviors identified from a self-and behaviors identified from a self-assessment survey (HRA) and member assessment survey (HRA) and member interview.interview.

Healthy dietHealthy diet

Physical activity/exercisePhysical activity/exercise

Dental hygieneDental hygiene

Tobacco useTobacco use

Solar injury protectionSolar injury protection

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DD2766 DD2766 Section 5 CounselingSection 5 CounselingHealth Promotion/CPSHealth Promotion/CPS

Heat/Cold Injury PreventionHeat/Cold Injury Prevention

Injury PreventionInjury Prevention

Stress ManagementStress Management

Suicide/Violence PreventionSuicide/Violence Prevention

Family Planning/Prevention of STDs Family Planning/Prevention of STDs

Prescription and OTC Medication UsePrescription and OTC Medication Use

Nutritional Supplements Nutritional Supplements

Complementary and Alternative HealthcareComplementary and Alternative Healthcare

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DD2766 DD2766 Section 5 CounselingSection 5 CounselingHealth Promotion/CPSHealth Promotion/CPS

Travel HealthTravel Health

Occupational ExposuresOccupational Exposures

Other Identified Risk Other Identified Risk BehaviorsBehaviors

Use USPSTF guidelines and Use USPSTF guidelines and

topic-specific handouts and topic-specific handouts and

materialsmaterials

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Member’s Responsibilities Member’s Responsibilities (RC)(RC)

Follow-up with civilian healthcare Follow-up with civilian healthcare provider for any non-service provider for any non-service connected health issues, clinical connected health issues, clinical preventive services, and PHA provider preventive services, and PHA provider recommendations.recommendations.

Provide documentation of completed Provide documentation of completed clinical preventives services and clinical preventives services and medical treatment to MDR medical treatment to MDR

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““Active Component” Active Component” vs. vs.

“Reserve Component”“Reserve Component” PHA Providers’ can facilitate “immediate” PHA Providers’ can facilitate “immediate”

initiation of management or expedite further initiation of management or expedite further evaluation as follows:evaluation as follows:

– Consults submitted to address health issues Consults submitted to address health issues identified during the PHA sessionidentified during the PHA session

– Lab tests ordered and followed-upLab tests ordered and followed-up

– Prescribed meds are entered into computer Prescribed meds are entered into computer system for pick-up at Pharmacysystem for pick-up at Pharmacy

– Educational MaterialEducational Material

– Schedule Health Promotion ClassesSchedule Health Promotion Classes

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QUESTIONS ?QUESTIONS ?