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Service Delivery Innovation Profile

Navy Medical Home Clinics, Staffed by Integrated Primary Care Teams and Supported by Web-Based Systems, Improve Screening Rates, Access to Care, and Patient-Provider Communication


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Snapshot

Summary

The Walter Reed National Military Medical Center (formerly National Naval Medical Center) created integrated medical home teams within its internal medicine department to provide personalized, coordinated, and proactive care to patients. The teams provide patient care, make appointments with offsite specialists, follow up with patients as needed, and integrate onsite behavioral health specialists when appropriate. A robust online medical portal and electronic personal health record support the care process, allowing patients to add information to their medical records and communicate via e-mail with team members, who, in turn, use the systems to identify patients who need followup care and to conduct virtual office visits. The program improved screening rates related to diabetes and breast cancer, enhanced provider continuity, access to care, staff satisfaction, and patient–provider communication, reduced emergency department use, and lowered overall health care costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of HEDIS® screening rates for diabetes and breast cancer, the percentage of visits where the patient is seen by his or her regular provider, various measures of access to care, emergency department use, the costs for treating patients, satisfaction of staff, and the number of virtual visits and e-mail communications between providers and patients.
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Developing Organizations

Walter Reed National Military Medical Center (formerly National Naval Medical Center)
Bethesda, MDend do

Use By Other Organizations

Similar medical home models are being created or considered at several other Naval facilities, including the Naval Medical Center San Diego, the Naval Health Clinic Patuxent River, the Naval Hospital Pensacola, the Naval Health Clinic Quantico, and the Naval Health Clinic Annapolis.

Date First Implemented

2008
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Patient Population

The program serves active duty and retired Navy personnel and their adult dependents, primarily in the Washington, D.C., area. The average age is 67 years, with more than one-half (57 percent) of patients having one or more chronic illnesses.end pp

Problem Addressed

The civilian and military health care system in the United States often provides uncoordinated care to patients, especially those with chronic illnesses. Providers have limited time to spend with patients and often lack effective systems for communicating with them. As a result, the responsibility for coordinating followup care and scheduling appointments with specialists or behavioral health providers often falls to patients, who are generally ill equipped to perform such tasks. Medical homes can help to address these problems, yet few military or civilian primary care clinics follow this model.
  • Poorly coordinated care: Most primary care practices lack the staff and technology to effectively coordinate patient care. The problem is especially severe in military and other government-run clinics, which seldom provide care coordination and management activities and, in some cases, preventive care to veterans and active duty personnel with chronic health conditions.1
  • Lack of information technology (IT): Military and civilian health care facilities often do not have information systems that can improve communication between patients and providers, between primary care providers and specialists, and across care sites. When such systems are available, clinicians do not always use them.
  • Failure to integrate behavioral health: Integrating a behavioral health specialist, such as a psychotherapist, into civilian or military primary care settings can improve patient and provider satisfaction, reduce symptoms, improve patient functioning, and lower health care costs.2 Patients are also more likely to make an appointment with an onsite behavioral health specialist than with one located elsewhere.3 Despite these potential benefits, few civilian or military primary health centers offer onsite behavioral health services.
  • Unrealized potential of medical homes: Providing patient-centered, coordinated care reduces the need for costly emergency department (ED) visits and hospitalizations. Denmark organizes its entire health care system around patient-centered medical homes that promote care coordination, which has contributed to its having the lowest per capita health expenditures among all Western developed countries.4 However, few military or civilian primary care clinics in the United States follow this model.

What They Did

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Description of the Innovative Activity

The Walter Reed National Military Medical Center created integrated medical home teams within its internal medicine outpatient clinics to provide personalized, proactive, coordinated care and care management to patients. The teams provide care, make appointments with specialists, follow up with patients as needed, and integrate behavioral health specialists at the point of care when appropriate. A robust online medical portal and personal health record system support the care process, allowing patients to add information to their medical records and communicate via e-mail with team members, who, in turn, use the systems to identify patients who need followup care and to conduct virtual office visits. Highlights of the medical home model follow:

  • Team make-up and caseload: Each medical home team serves about 3,000 patients. The team consists of two internal medicine physicians, a physician assistant, a registered nurse who typically serves as the care manager, three licensed practical nurses, and two or more administrative assistants. All members are housed in one team office to improve collaboration, communication, and accountability. As discussed further below, behavioral health consultants (including psychologists and licensed clinical social workers), dietitians, and mind–body medicine therapists are available onsite, with each specialist serving up to 6,000 patients.
  • Comprehensive, personalized, proactive care and care management: Each team provides comprehensive care based on individual patient needs, referring patients to military or civilian specialists as needed for preventive, acute, and chronic illness care that cannot be provided onsite. A team member makes any needed specialist appointments before a patient leaves the clinic and then contacts the patient by e-mail or phone to provide test results or other followup information related to the visit. Previously, the patient was responsible for making these appointments and obtaining this information.
  • Open scheduling, virtual visits, e-mail/phone communications: To make access to care as easy as possible, the clinic offers open scheduling that allows for same-day appointments for acute care and appointments within 3 days for routine care. In addition, patients are encouraged to call or e-mail providers with questions or prescription refill requests, someone always answers the phone (rather than forcing patients to leave a message, as occurred previously), and providers call patients back to answer their questions in a timely manner. Patients are also encouraged to schedule virtual (rather than face-to-face) visits with providers when appropriate. (See next bullet for more information.)
  • Nontraditional services within primary care setting: To allow patients easier access to additional services, the program provides the following specialists to patients within the primary care practice. For most of these services, the patient can meet with the specialists immediately after their primary care doctor’s visit or schedule a followup visit.
    • Behavioral health consultants (psychologists): These specialists offer 30-minute appointments with patients to help them cope with various medical conditions, change lifestyle habits, overcome family or relationship difficulties, manage stress, and deal with bereavement, depression, anxiety, or anger problems.
    • Diabetic educators: These specialists provide patients with a new or established diagnosis of diabetes with comprehensive medical management and education. Patients can schedule an appointment for educational classes or individual case management.
    • Dietitians: Dietitians offer individualized nutrition education and counseling for patients with chronic diseases, such as obesity, diabetes, heart disease, and hypertension.
    • Mind–body medicine therapists: These therapists offer educational/experiential sessions (either individual or group) and classes to patients to help reduce stress. They focus on teaching patients self-care skills, such as meditation, yoga, guided imagery, expressive arts, and mindful living skills.
    • Clinical pharmacists: These pharmacists perform comprehensive medication counseling and review, medication reconciliation, and screening for drug-related problems.
    • Health educators: These educators provide education on specialized topics, such as tobacco cessation, stress management, decisionmaking, anger management, and sexual health. These services are available through individual appointments, group support sessions, online programs, and shared medical appointments.
  • Web-based personal health records and systems to support care management: A Web-based portal allows patients and providers to better manage care.
    • Patient-input information via Web site: Through a secure Web site, patients can register, provide information and answer questions about their health, and check in before an office visit. Patients are also encouraged to enter clinical information, such as recent blood glucose or blood pressure readings that may be helpful to providers. Patients can use the system to communicate with providers and health care teams and to schedule a virtual office visit with a team member, with the software providing templates and other information to enable the virtual visits and previsit screening. Patients can also use the system to rank their satisfaction with providers. Online enrollment began in May 2009, and, within 2 months, about 15 percent of patients had registered. Team members hope to ultimately enroll about 70 percent of patients in the online system.
    • Electronic kiosk: This kiosk allows patients to sign in for appointments by swiping their identification card (rather than waiting at the front desk to speak to a clerk), validate and update demographic information, receive alerts about overdue tests or immunizations, and answer clinical questions before seeing their primary care provider. Data entered into the kiosk flows into the electronic medical record, thus providing doctors with immediate alerts when patient-entered information creates the need for intervention during the visit, and also allowing for immediate feedback on a patient’s mental and physical well-being during the visit.
    • Provider support through alerts and performance feedback: The system provides physicians and team members with a wealth of data on patients to help providers better manage care, with secure access available from outside the office. For example, the system flags patient records and sends out alerts when patients have not been seen or screened as recommended by best practices and provides disease management tools to improve care for patients with chronic illnesses. The system also provides individual physicians and teams with comparative performance information on several HEDIS® (Healthcare Effectiveness Data and Information Set) measures (e.g., blood glucose for those with diabetes, breast cancer screening), productivity, and patient satisfaction. The system also promotes colleague-to-colleague correspondence to facilitate sharing of best practices.
    • Facilitating followup care for patients seen in ED or hospital: The system alerts the team when a patient has been treated by the ED or hospitalized in the past 24 hours. This communication enables the team to arrange appropriate followup care.
  • Ongoing patient oversight: An advisory council made up of medical home patients regularly evaluates clinic care processes, voicing any concerns and making recommendations to improve care.

Context of the Innovation

The Department of Defense provides medical care to active duty military personnel, retirees, and eligible dependents of both groups through a local military medical center. In this "closed" system, active duty personnel pay nothing for their care, whereas others pay a small fee for each visit or service. In 2007, Navy doctors and researchers at the National Naval Medical Center's Department of Internal Medicine, which served roughly 24,000 patients on an outpatient basis, began investigating how to restructure its primary care delivery system. The goal was to move away from a focus on disease and care episodes to a proactive, patient-centered approach that emphasizes primary and preventive care. The developers borrowed heavily from medical home models developed by the Patient-Centered Primary Care Collaborative, based in Washington, D.C., which emphasizes patient-focused care management and inclusion of onsite behavioral health services.

In response to rising health care costs, low patient satisfaction relative to the private sector, and a continuing decline in health and health care outcomes, the Military Health System (MHS) selected the patient-centered medical home (PCMH) model of care in 2008, and the MHS PCMH Policy was signed in September 2009. Subsequently, each Service developed its own detailed implementation instruction. The Tri-Service PCMH Advisory Board was chartered in July 2010 to provide governance over the implementation and sustainment effort at more than 430 MHS primary care practices.

Did It Work?

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Results

The medical home team program has improved screening rates related to diabetes and breast cancer; enhanced provider continuity, access to care, staff satisfaction, and patient–provider communication; reduced emergency department use; and lowered overall health care costs.

  • Improved screening rates: In a previous 24 month study, the percentage of women age 52 to 69 who had one or more mammograms increased from 74 to 90 percent. The percentage of patients with diabetes who had blood glucose screenings in the previous 3 months and low-density lipoprotein testing in the past year rose from 50 percent to more than 90 percent.
  • Enhanced provider continuity: The percentage of visits during which patients saw their regular primary care manager/provider (rather than an unfamiliar provider) rose from 55 percent to nearly 90 percent. After the launch of two additional teams in January 2009, this rate rose from 63 to 78 percent for one team and from 48 to 70 percent for the other.
  • Enhanced access to care and patient–provider communication: As noted, medical home patients receive same-day access for acute care and can see a provider within 3 days for routine or preventive care. By contrast, patients not enrolled in medical home clinics wait an average of 3 days to see a doctor for acute care and 7 days for routine care. In addition, virtual visits and e-mail communications between providers and patients have increased fourfold since program implementation, with no decline in face-to-face visits. Using pre-implementation data from 2007 and 2008 as well as post-implementation data from 2010 and 2011, overall access to care increased by 7 percent.5
  • Reduction in ED use: The previously mentioned study using data from 2007 - 2011 indicated a decrease in ED utilization by 75.3 percent.5
  • Lower costs, particularly for patients with chronic conditions: Using 6 quarters of pre- and post-implementation data before and after the PCMH transition in January 2009, costs were 11 percent lower for patients with chronic conditions and 7 percent lower for patients without chronic conditions compared to a similar clinic, or $83 and $13 reductions per quarter respectively.6
  • High satisfaction: A survey conducted in the fall of 2011 indicated that 75 percent of staff who volunteered to be surveyed were satisfied with the medical home.5

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of HEDIS® screening rates for diabetes and breast cancer, the percentage of visits where the patient is seen by his or her regular provider, various measures of access to care, emergency department use, the costs for treating patients, satisfaction of staff, and the number of virtual visits and e-mail communications between providers and patients.

How They Did It

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Planning and Development Process

Key steps included the following:

  • Choosing staff for pilot: Department heads handpicked staff for the first team 9 months before launch of the medical home clinic. Recognizing that the structure and culture would dramatically change, they chose staff based on their flexibility and willingness to participate in a new model.
  • Conducting team-building exercises: Numerous team-building exercises were held to create a collaborative team.
  • Refining model and care processes: The team refined the medical home model and patient flow processes to meet the needs of the patient population, including determining how behavioral health and referrals would be integrated into patient care and how care coordination activities would be managed.
  • Creating physical infrastructure: Program leaders designated a common office for the entire team, with the goal of promoting teamwide communication. They also decided to redesign the clinic's waiting area to resemble a comfortable lounge.
  • Creating IT: During the team-building process, program developers worked with IT specialists to create the portal and electronic personal health record system, using technology from RelayHealth to support the patient flow process. IT specialists also designed a medical home management system for clinicians that included population management functions, indepth data search capabilities, and point-of-care content support using evidence-based medicine. Team members received training on all of these systems. Staff copied and pasted patient records into the system once it had been developed.
  • Introducing patients to model: All enrollees in the pilot program (approximately 1,200 patients) received a letter explaining the new medical home model and inviting them to a town hall meeting to learn more about it. The team held two meetings per month over a period of 10 months, with roughly 5 percent of enrollees attending. Program developers also engaged in other activities to promote education about the model among patients.
  • Program expansion: Two years after the first pilot team was launched, the medical center expanded the program. At present, 8 teams serve roughly 24,000 patients. Medical center leaders plan to create additional medical home clinics to serve children, adolescents, wounded soldiers, and geriatric patients.

Resources Used and Skills Needed

  • Staffing: Initially, the program required no new permanent staff, as existing staff were retrained to work in the medical home clinic structure. Registered nurses, who perform much of the care coordination work, are critical to the program's success. To ensure successful team-building, coaches and consultants promoted collaboration and commitment to the new patient care model.
  • Costs: Data on the cost of implementing the model, including development of the supporting IT systems, are not available.
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Funding Sources

National Naval Medical Center
The innovation was internally funded by the National Naval Medical Center.end fs

Tools and Other Resources

National Committee for Quality Assurance (NCQA) standards and guidelines for Physician Practice Connections®— Patient-Centered Medical Home (PPC-PCMH™). Available at: http://www.ncqa.org/tabid/631/Default.aspx.

NCQA's State of Health Care Quality report is produced annually to monitor and report on performance trends over time, track variations in patterns of care, and provide recommendations for future quality improvement. To develop this report, NCQA uses data from HEDIS®, a set of measures that assess how often patients receive care that conforms to evidence-based guidelines. Available at: http://www.ncqa.org/tabid/836/Default.aspx.

Information on the Patient-Centered Primary Care Collaborative (a coalition of major employers, consumer groups, patient-quality organizations, health plans, labor unions, hospitals, physicians, and others working to develop the patient-centered medical home). Available at: http://www.pcpcc.net.

American College of Physicians, Internal Medicine. Patient-Centered Medical Home. Available at: http://www.acponline.org/running_practice/pcmh.

Adoption Considerations

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Getting Started with This Innovation

  • Empower stakeholders to develop program: Because implementing the model represents a major cultural change, clinic or practice leaders must be empowered to reassign staff and mandate changes in job assignments.
  • Choose and refine a medical home model: Several medical home models are under development by government and private-sector organizations. Choose a model that can effectively serve the practice's population, taking into consideration age, demographics, computer usage and access, and chronic disease management needs. The model can be redesigned to conform to patient needs, and the care team may be expanded to include behavioral health and other specialists as needed.
  • Identify IT needs: Several commercial IT products can support the medical home model. Select systems that "talk" to each other and best serve patient needs.
  • Invest in team building: Set aside an appropriate number of weeks for training and team-building exercises. If effective team building does not occur, the staff will struggle to work collaboratively.

Sustaining This Innovation

  • Be prepared to innovate: Periodically reexamine the model's strengths and weaknesses, making changes as needed to ensure it remains patient centered and achieves its goals.
  • Improve integration of disparate information systems: Navy officials eventually hope to create a comprehensive information management system that will allow teams to access what are currently disparate medical and patient health records through the portal. The ultimate goal is to provide evidence-based resources at the point of care, a patient-centered education portal, and assistance with check-in procedures for patients.
  • Continue team-building and coaching efforts as program expands: After launching the second medical home team, the clinic cut back on coaching and team-building efforts due to time constraints. The team's performance suffered as a result, and ultimately program developers decided to provide the same team-building exercises given to the first team.

Use By Other Organizations

Similar medical home models are being created or considered at several other Naval facilities, including the Naval Medical Center San Diego, the Naval Health Clinic Patuxent River, the Naval Hospital Pensacola, the Naval Health Clinic Quantico, and the Naval Health Clinic Annapolis.

More Information

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Contact the Innovator

Kevin A. Dorrance, MD, FACP
CAPT (s) / MC / USN
Chief, General Internal Medicine Service
Walter Reed National Military Medical Center
8901 Wisconsin Avenue
Bethesda, MD 20889
(301) 295-4805
E-mail: kevin.a.dorrance.mil@health.mil

Sean M. Lynch
Senior Project Manager
General Internal Medicine Service
Medical Home
Walter Reed National Military Medical Center
8901 Wisconsin Avenue
Bethesda, MD 20889
(301) 319-4399
E-mail: sean.m.lynch.ctr@health.mil

Innovator Disclosures

Dr. Dorrance and Mr. Lynch reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Walter Reed National Military Medical Center Medical Home Web page. Available at: http://www.wrnmmc.capmed.mil/SitePages/home.aspx.

Dorrance KA, Ramchandani S, LaRochelle J, et al. Protecting the culture of a patient-centered medical home. Mil Med. 2013;178(2):153-58. [PubMed]

Nathan M. The patient-centered medical home in the transformation from healthcare to health. Mil Med. 2013;178(2):126-7. [PubMed]

Savage A, Lauby T, Burkard JF. Examining selected patient outcomes and staff satisfaction in a primary care clinic at a military treatment facility after implementation of the patient-centered medical home. Mil Med. 2013;178(2):128-34. [PubMed]

Christensen EW, Dorrance KA, Ramchandani S, et al. Impact of a patient-centered medical home on access, quality, and cost. Mil Med. 2013;178(2):135-41. [PubMed]

Dorrance KA, Ramchandani S, Neil N, et al. Leveraging the military health system as a laboratory for health care reform. Mil Med. 2013;178(2):142-5. [PubMed]

Hudak RP, Julian R, Kugler J, et al. The patient-centered medical home: a case study in transforming the military health system. Mil Med. 2013;178(2):146-52. [PubMed]

Footnotes

1 Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001. Available at: http://www.nap.edu/catalog.php?record_id=10027.
2 Strosahl K, Robinson P. The primary care behavioral health model: applications to prevention, acute care and chronic condition management. New York: Springer; 2008. Collaborative Medicine Case Studies. Available at: http://www.springerlink.com/content/gg6862k813412638/.
3 van Orden M, Hoffman T, Haffmans J, et al. Collaborative mental health care versus care as usual in a primary care setting: a randomized controlled trial. Psychiatr Serv. 2009;60(1):74-9. [PubMed]
4 Beal A, Doty M, Hernandez S, et al. Closing the divide: how medical homes promote equity in health care—results from The Commonwealth Fund 2006 Health Care Quality Survey. The Commonwealth Fund, June 2007. Available at: http://www.commonwealthfund.org/~/media/Files/Surveys/2006/The%20Commonwealth%20Fund%202006%20%20Health%20Care%20Quality%20Survey
/Closing_divide%20pdf.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
5 Savage A, Lauby T, Burkard JF. Examining selected patient outcomes and staff satisfaction in a primary care clinic at a military treatment facility after implementation of the patient-centered medical home. Mil Med. 2013;178(2):128-34. [PubMed]
6 Christensen EW, Dorrance KA, Ramchandani S, et al. Impact of a patient-centered medical home on access, quality, and cost. Mil Med. 2013;178(2):135-41. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 31, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.