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Military Update

Care, access seen rising under 'Medical Home' concept

Most military beneficiaries haven’t heard of PCMH or “patient-centered medical home,” a civilian-conceived strategy to improve managed care.

Yet 655,000 military beneficiaries who use base clinics and hospitals have been enrolled with a PCMH team over the past 14 months and that number is projected to double this year and double again, to 2.5 million beneficiaries in 2012.

The military’s direct care system, in effect, quietly is orchestrating its own major health care reform. And though it didn’t conceive the concept or that mouthful of an acronym, the military might be showing the nation how to embrace PCMH and to clear some of its highest hurdles.

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After more than a year’s experience at more than 50 pilot sites across the military health care system, confidence in the concept is rising among health care providers and beneficiaries, reported senior health officials this week at the Military Health System Conference held in National Harbor, Md.

The three service medical departments use slightly different names for PCMH.  Sailors and Marines are being told about “Medical Home Port.”  Air Force touts a new “Family Health Initiative.”  Army has called it PCMH but also “Community-Based Medical Home.”

In every case, beneficiaries use military-run clinics for primary care and are assigned to a doctor, by name, supported by a small professional staff or team.  That team is responsible for managing all health care for empanelled patients including specialist referrals when needed.

Patients see familiar faces with every visit, assuring continuity of care.  Appointments and tests get scheduled promptly.  Care is delivered face-to-face on site or, when appropriate, remotely, using tools like electronic health records, secure e-mails and interactive websites. The same tools guarantee 24-hour health advice.  The team encourages healthy lifestyles and it schedules preventive health screening as appropriate for age and gender.

Being shelved is a long-held notion that a military clinic’s effectiveness is best measured by number of patient visits, tests run and procedures performed.  The old scorekeeping, say PCMH advocates, does measures care provided and usually protects a clinic’s budget.  But it doesn’t correlate to patient satisfaction or levels of health achieved.

Defense health executives and some family practice doctors had been tracking for several years the patient-centered concept evolving in civilian medicine.  It promised improved access and better care while reducing unneeded tests and referrals, and slowing of overall cost growth.

What spurred Defense officials to order the services to move toward patient-centered reform was a 2008 beneficiary survey showing users of military clinics markedly less satisfied with their health care experience than beneficiaries using the more costly TRICARE network of civilian providers.

Military commanders noticed too as they fielded a rising number of complaints from stressed families who couldn’t get appointments, had long wait times at clinics and to gain appointments with specialists.

Deborah Mullen, wife of Navy Adm. Mike Mullen, chairman of the Joint Chief, movingly described frustration among spouses in a speech Monday at the health care conference.  In it she urged the health system to recognize rising levels of post-traumatic stress in families who can’t get away from war.

Some spouses, Mrs. Mullen said, refer to a “15-and-1” rule in trying to get needed care.  “It goes like this: No matter what may be bothering you from a health perspective, you’re allowed to discuss one symptom and only then for 15 minutes.  That’s it,” she said.

“If we accept, as we have, that spouses suffer from PTS all their own, and if we know, as we do, that PTS manifests itself in many ways in many different people, why would we not accept the need to treat the whole person?  Why would we fail to look at the totality of issues confronting a young spouse?”

Patients assigned to Medical Home teams won’t know those frustrations, said Navy Capt. Maureen O’Hara Padden, executive officer at Naval Hospital Pensacola, Fla.  Pensacola is one of seven major test sites for PCMH.  Padden is being reassigned to the Navy surgeon general staff to serve as program manager for Medical Home Port.

At Pensacola, she said the first hurdle in setting up teams was to make sure all providers shared the same vision for what would be delivered to patients.  She describe that vision this way:

 “If you call today I’m going to get you in.  If you need to be seen in the next week I’m going to get you in.  I’m going to strive to see that you see your doctor as much as possible.  By the way, you should never have to go to the emergency room because I’m here for you. It may not always be me who sees you; it may be my nurse.  It could be my partner [physician] if I’m out of town.  But somebody on the team will give you the right care at the right level at the right time at the right place.  It might not be face-to-face; it might be electronic or it might be over the phone.”

Kenneth Canestrini, former commander of Dewitt Army Hospital, is coordinating integration of PCMH for the Army surgeon general, after leading a two-year effort to improve patient access.  The key, he said, will be strengthening staffs behind team doctors.  Army’s ratio of staff to primary care doctor will climb from 2.8 to 3.1, or more than 10 percent. 

Army lags Air Force and Navy in implementing PCMH. It’s goal is to have PCMH service wide by fiscal 2016.

Vice Adm. Adam M. Robinson, Navy’s surgeon general, told conferees Medical Home is not brick and mortar but rather “a philosophic construct of how you deliver care,” emphasizing disease prevention, 21st century communication and using the full talents of entire medical staff.

“It will require us to change how we think.  We cannot continue to have clinics [only open] seven to three, Monday through Friday, and holidays off,” Robinson said.  He added, “It is truly a game changer.”

To comment, send e-mail to milupdate@aol.com or write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111

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