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Care, access up under medical health system

Most military beneficiaries haven't heard of the civilian-conceived strategy to improve managed care called patient-centered medical home, or PCMH.

Yet 655,000 military beneficiaries who use base clinics and hospitals have been enrolled with a PCMH team over the past 14 months. 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, is quietly orchestrating its own major health care reform. And though it didn't conceive the concept or that mouthful of an initialism, the military might be showing the nation how to embrace PCMH and to clear some of its highest hurdles.

Senior health officials reported last week at the Military Health System Conference held in National Harbor, Md., that 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.

The three service medical departments use slightly different names for PCMH. Sailors and Marines are being told about "Medical Home Port." The Air Force touts a new "Family Health Initiative." The 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 schedules preventive health screenings as appropriate for age and gender.

Being shelved is a 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 measure care provided and usually protects a clinic's budget. But it doesn't correlate to patient satisfaction or levels of health achieved.

Department of 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 Department of Defense officials to move toward patient-centered reform was a 2008 beneficiary survey showing users of military clinics were 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, and had long wait times at clinics and to gain appointments with specialists.

Deborah Mullen, wife of Navy Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, described frustration among spouses in a speech last week 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.

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.

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."

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