Military Health System (MHS) Patient Centered Medical Home .

Military Health System (MHS)Patient Centered Medical Home (PCMH)Brief to Recovering Warrior Task ForceTRICARE Management ActivityOfficer of the Chief Medical OfficerApril 2013

Overview PCMH BackgroundMHS Primary Care TransformationMHS PCMH GoalsPCMH Care in a Medical Treatment FacilityWounded Warrior Care in the MHS

PCMH Background Term introduced by the American Academy of Pediatrics(AAP) in 1967 - became AAP policy within 10 years Adopted by Family Medicine in 2002 as part of the “Futureof Family Medicine” project– Concept now fully endorsed by the AAP, American Academyof Family Medicine and American College of Physicians– Large third party payers, employers, and health plans– Key component of current health care reform plan Patient-Centered Primary Care Collaborative is leadingproponent of the evolving model: -presentationmaterials

Seven Principles of a PCMH1. Personal Physician: Primary Care Manager (PCM) based andassigned as the PCM by Name (PCMBN)2. Physician Directed Medical Practice: The personal physician leadsa team who collectively take responsibility for patients’ ongoing care3. Whole Person Orientation: Team takes a holistic view of thepatient and underlying causes health problems versus just treatingepisodic acute care4. Care is Coordinated or Integrated across all elements of thecomplex health care system5. Quality and Safety: Evidenced-based model of care, DoD/VAClinical Practice Guidelines, inpatient/outpatient quality reporting andDOD Patient Safety Program6. Enhanced Access: Formal policy defining access standards foracute, routine and wellness visits, open scheduling, expanded hoursand new options for communication (e.g. secure messaging, etc.)7. Payment Recognizes Added Value provided to patients who have4a patient-centered medical home.4

MHS PCMH Implementation In 2008, Military Health System (MHS) selected PatientCentered Medical Home (PCMH) model of care to:– Maintain maximum patient satisfaction– Increase evidence-based effectiveness of care MHS PCMH Policy signed Sep 2009 directed development ofconsistent Army, Navy and Air Force PCMH operatinginstructions and implementation in all primary care clinics– Tri-Service governance– Selected the National Center for Quality Assurance (NCQA) forformal PCMH recognition– Provides external review of civilian and military primary carepractices across the United States– Three possible levels of Recognition: 1, 2 and 3 (highest)– MHS Goal is for all practices to achieve Level 2 or 3

PCMH Policies DOD/HA Policy 09-015 “Policy MemorandumImplementation of the ‘Patient-Centered Medical Home’Model of Primary Care in MTFs”, September 2009 Army - Operation Order 11-20, “Army Patient-Centeredmedical Home”, January 2011 Navy – BUMED Instruction 6300.19 “Primary CareServices in Navy Medicine”, May 2010 Air Force Instruction 44-171, “Patient Centered MedicalHome and Family Health Operations”, January 2011

MHS PCMH Goals Implement PCMH model of care at all 435 primarycare practices (Family Medicine, Internal Medicine,Pediatrics, Community Based Medical Homes andWarrior Transition Units)– Near-term – improve Primary Care Manager (PCM) continuity,access to care and patient satisfaction– Mid-term – manage demand, integrate Behavioral Health intoprimary care, increase percent of enrollees’ primary caredelivered in the PCMH, decrease specialty care utilization,reduce private sector care costs, improve quality measures andincrease medical readiness of our warfighters and their families– Longer-term – Improve beneficiary health status, increaseMedical Treatment Facility (MTF) capacity and then recaptureenrollment from private sector and ultimately, optimize MTFresources7

MHS NCQA Recognition Status TotalPrimaryCarePractices43592 Percent or 157 of MHS’ 171 NCQArecognized practices are NCQA Level 3 PCMHsMHS PCMH practices continue to maturefollowing NCQA recognition% Total% ProjectedCY11 NCQA CY12 NCQA Total NCQACY13TotalTotalPracticesLevel 2 or 3CY14% CompleteRecognized Recognized RecognizedUndergoing RecognizedRecognizedNCQA Levelas of 31 Dec ProjectionsCY14Level 2 or 3 Level 2 or 3 Level 2 or 3Recognition end CY13End CY142/3134812317139%15732976%106435100%

Enrollee Care in an MTF PCMH Continuity of Care with Primary Care Manager(PCM) by Name Enhanced Access to Acute, Routine andWellness care Secure Messaging – MTF Prime beneficiaries atall 435 primary care practices will be able to sendemails to PCM 24 hours a day by August 2013 Individualized, Comprehensive Care Plans, whenapplicable Embedded Internal Behavioral HealthConsultants (social worker or psychologist)

Enrollee Care in an MTF PCMH (Con’t) Patient, Family and Provider collaboration toaddress and resolve barriers to self-caremanagement and achievement of health goals Medication reconciliation Case management (if applicable) Care coordination Care transitions management Clinical summaries of visits and copy of medicalrecords at transition

Enrollee Care in an MTF PCMH (Con’t) MHS’ electronic medical record enhanced with TriService Workflow (TSWF) templates– Screen patient at each visit using evidence-basedguidelines Height/weightExerciseAlcohol UseSmokingGeneral Sense of HealthDepression including PTSD– 16 clinical practice guidelines (CPGs) embedded in TSWFcore forms– 15 more TSWF specialty forms in pilot stage ordevelopment with embedded CPGs

Medical/Non-Medical Case Managementand Care Coordination PCMH Case Management––––––Interface with PCMCoordinate care/specialty appointmentsHelp obtain documentation of non-PCM visitsAvailable to patient phone/email/in-personArrange home health, handicap placards and other servicesCare coordination/management is a NCQA “Must Pass”requirement to achieve Level 2/3 PCMH WTU Case Management (medical)– All of the above– All patients in WTUs have at least one medical Case Manager– Interfaces with non-medical Case Management

Army Wounded Warrior Care Location of Healthcare for Wounded, Ill and Injured(WII) soldiers depends on severity and duration ofmedical problems– WII who do not meet the criteria for Warrior Transition Unit(WTU) stay in their units and are seen in PCMHs or SoldierCentered Medical Homes (SCMH) This category represents the vast majority of WII Army PCMHs– Currently 62 of 144 total Army primary care practices are NCQArecognized Level 2 or 3 PCMHs with another 82 underway– All Army PCMHs will be NCQA-recognized by 31 Dec 13

Army’s WTU Programs WTU entry criteria: soldiers needing at least six months of care,require case management and unable to contribute to their units WTUs will be NCQA-recognized Level 2 or 3 PCMHs by 31 Dec 13– Enrolled in WTU Clinic for Primary Care Management– Assigned a WTU Case Manager for medical case management– Enhanced access and care coordination, case management and embeddedbehavioral health specialists– Squad leader for non-medical case management

Air Force Wounded Warrior Care Air Force WII Airmen receive healthcare in AF PCMHs– All AF’s Family Health and Pediatrics clinics have beentransformed to PCMHs based on AF criteria– 40 out of AF’s 171 primary care practices are Level 3 PCMHswith another 26 underway– All 171 AF practices will be 100% NCQA-recognized by 31 Dec 14– Most severely WII are enrolled in the Air Force Warrior Program(AFW2) and receive additional, non-medical care management

Navy Wounded Warrior Care Navy Wounded Warriors are seen in the Navy’sPCMH “Medical Home Port” (MHP) practices– 67 out of the Navy’s 110 primary care practices are NCQArecognized Level 2/3 PCMHs with another 43 underway– Navy will be 100% NCQA-recognized by 31 Dec 13 Category 2 and 3 Marine Wounded Warriors areenrolled to and seen in Wounded Warrior clinics– Camp Pendleton– Camp Lejeune– These clinics are in the queue for NCQA recognition

Regina M. JulianDirector, MHS PCMH Primary Careregina.julian@tma.osd.milPhone: 703-681-6216

Back-Up Slides

TSWF Embedded CPGs COPDAsthmaLow Back PainMajor Depression PTSDBipolar DisorderChronic Opioid TherapySubstance use DisordersTobacco UseChronic Heart FailureIschemic Heart DiseaseUncomplicatedPregnancy

Piloted or Future TSWF CPG FormsUseStatusIncludes CPGs for Diabetes, Hypertention, DislipidemiaIn Pilot Testingand ObesityFunded?Low Back Pain CPGIncludes Low Back Pain CPGIn Pilot TestingYesIntegrated Behavioral Health ConsultantIntended for use by all IBHCs in the PCMHIn Pilot Testing prior to DeploymentYESPulmonary CPGIncorporates the Asthma and COPD CPGs for use in thePCMHIn Queue for Pilot Testing and Deployment YESSustance & Tobacco Use Disorder CPGIncorporates the Substance Use Disorder and TobaccoUse Disorder CPGs for use in the PCMHIn Queue for Pilot Testing and Deployment YESNursingIncludes the nurse/tech/medic screening sectioncurrently in Core, as well as standardized documentationIn final phase of primary developmentworkflow for common procedures, medicationadministration, and pt educationTSWF AIM FormMetabolic CPGChronic Opioid Theraepy CPGBH for the PCMIntended for use with chronic pain patients on chronic In beta testing prior to secondaryopioid therapy in the PCMHdevelopment and pilot testingIntended for use by primary care providers in the PCMHcaring for patients with common BH disorders,Concept phaseincorporates the Depression, PTSD, & Bipolar CPGsYESNOYESYES

Piloted or Future TSWF CPG Forms (Con’t)TSWF AIM FormUseOrthopedics/Sports MedicineRequested by customers, intended to support primarilyspeciatly workflow for musculoskeletal conditions,Concept phaseincluding pre/post-op appts, procedures, etc.OB/GYNPhysical TherapyGeriatricNeuro/mTBICardiovascular CPGClinical PharmacyIntended to support OB patients in both FM and OB,based on Uncomplicated Pregnancy CPG and otherindustry evidenceRequested by customersStatusNOBeta TestingNOWait ListedNOIntended to support the delivery of care for patients with In beta testing prior to secondarycommon geriatric conditions and risk factors in the PCMH development and pilot testingIntended to support PCMH management of mTBIaccording to CPG, headache, seizures, other commonWait Listedneuro conditions.Intended for use by primary care to manage pts withCardiovascular disorders, based on the CPGs for stroke,Wait ListedMyocardial Infarction, Congestive Heart Failure andPeripheral Vascular DiseaseIntended to support clinical pharmacists managingchronic disease, coumadin therapy, polypharmacy, etc.Funded?Wait ListedNOYESYESNO

MHS PCMH Implementation In 2008, Military Health System (MHS) selected Patient Centered Medical Home (PCMH) model of care to: – Maintain maximum patient satisfaction – Increase evidence- based effectiveness of care MHS PCMH Policy signed Sep 2009 directed development of consistent