garrison care: the patient centered medical home and our active duty maureen o’hara padden md mph...
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Garrison Care:The Patient Centered Medical Home and our
Active Duty
Maureen O’Hara Padden MD MPH FAAFPCAPT, MC, USN (FS)
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Disclosure StatementMaureen Padden and all others
involved in the planning, development and presentation of this CME activity provide the following Disclosure information:
"Nothing to disclose"
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History of PCMH
• Roots in the civilian healthcare system• Joint Principles of the PCMH published by
AAFP, AAP and ACP in 2007• Approach to providing comprehensive
primary care that emphasizes patient/provider relationship
• Leverages team to provide coordinated care• Facilitates partnership• Not brick and mortar; concept of care• Anchored in quality and safety
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PCMH Strategy• Improve physician / patient relationship• Improve access, quality and control cost of care • Increased costs and poorer health outcomes
when compared to other developing countries– U.S. ranks # 37 in quality but #1 in per capita costs
• High utilization of technology/procedures in US:– Drives misperception that healthcare is too
expensive– Overuse exposes patients to potential adverse
events and errors
• Inappropriate use of the ER for primary care
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Top Customer Service Issues*:
Getting appointments, Clinic wait times, Specialist availability, Finding parking
Patient Satisfaction with MHS
5
Satisfaction with Health CareTRICARE Prime Enrollees
Source: *DMDC Survey Oct ’10 -Tricare Update SECNAV Retiree Council April 2012
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Improving the US Healthcare System
Solutions limited:
Raise TRICARE fees (increase cost sharing)
Cut services / shrink coverage
Become more efficient
Everyone facing same challenges (Air Force, Army, VA, Civilians, etc)
U.S.: #1 for costs; 37th in quality
DoD healthcare inflation unsustainable
DoD beneficiaries less satisfied with direct care
Sequestration6
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MHP: Navy’s Version of PCMH Model
NAVMED INST 6300.19 • Medical Home Port (MHP)
Instruction addresses the following:
o Changes in staff roles and responsibilities (e.g. team-based approach to care)
o Changes in business rules (e.g. enrollment and patient management, appointing, access)
o Use of Information Management/Information Technology (IM/IT) tools (e.g. secure messaging, clinical informatics tools)
o Evaluating MHP using standardized metrics (e.g. NCQA evaluation)
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Medical Home vs Managed Care
• Medical Home means– Physician-patient
relationship– Patient-centered,
personalized care– Preventive services, fewer
ER visits– Less hospitalization, better
tracking– Physician support and
feedback– Healthier, engaged patients– Fiscal savings through
comprehensive, coordinated care
• Managed Care means– Systematic “gatekeeper”
relationship – Contractually-dictated
care – Patients get “partialist”
care with services carved out
– Physicians handcuffed by “one size fits all model”
– More rules and unhappy patients
– Fiscal savings by limiting access to services
Source: Illinois Academy of Family Physicians
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MOU Signed Between HQMC and BUMED
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PCMH in Garrison Care
• Operational mission is paramount• Navy Medicine in the Fleet:
– Large investment of providers/corpsman (~25%)– Proportionally small population per provider – Organizationally aligned to Line units– Important to keep up skills and competency
• BUMED / HQMC / Fleet Forces shared interest
• Scalable model that support operational requirements while ensuring quality care
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Enrollment in the Medical Home
• FCMH/MCMH seeks to evolve BMC’s/FLC’s to micro-practices
• Adjustments for other duties outside face to face continuity practice
• Successful planning will have impact on:o Readinesso PCMBN continuityo Team continuityo ER utilization and other leaks of primary careo Performance on quality metricso Costso Patient satisfaction
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Traditional → Group Practice Model
250 personnel
5000 personnel
10 Flight Surgeons available ~ 50% of
the time = 5 providers (FTE)
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What is the demand for care?
• Same day access (1.0%) of population• Future pre-booked access (0.5%)• Assume team of 4,000 active duty from 10
various squadrons and units combined:– 40 same day appointments (ACUT)– 20 future book appointments (EST)– Total visits: 60 each day for clinic (high end)
• If we assume a provider could see 20 patients a day, requirement is for 3 FTE…other 7 remain in squadron duties (doesn’t include Flight PE’s)
• Integrated practice, scalable in response to deployments…FS goes with unit
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ACUT
•Release and begin booking appointments up to 24 hours out for any reason
EST
• Future appointments used for all care outside the 24 hour window
PROC/SPEC
• Non-continuity services
• Walk in immunizations
• Flight Physicals
Standardized Appointing Supports Patient-
Centered Care
Appointing Goals
• EST: Third Next Available <7 days• ACUT: Within 24 hours for same day care• SPEC: Flight Physicals / Up chits• PROC: Immunizations Procedures• Appointment Mix of ACUT/EST: Probably 70% ACUT /
30% in operational world
14Do Today’s Work Today!
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Today’s Work Today• Do everything same day as much as
possible• Regardless of acuity• Decreases no shows• Preserves maximum capacity for
tomorrow and beyond• Only two types of good backlog:
– Medical need to schedule in the future– Patient preference
• Otherwise, see it today!!
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Standardized Continuity Template
MorningCheck In Physician Type
7:45:00 AM 8:00:00 AM ACUT
8:00:00 AM 8:20:00 AM ACUT
8:20:00 AM 8:40:00 AM ACUT
8:40:00 AM 9:00:00 AM ACUT
9:00:00 AM 9:20:00 AM EST
9:20:00 AM 9:40:00 AM ACUT
9:40:00 AM10:00:00
AM EST10:00:00
AM10:20:00
AM ACUT10:20:00
AM10:40:00
AM ADD-ON10:40:00
AM11:00:00
AM ADD-ON11:00:00
AM11:20:00
AM ADMIN11:20:00
AM11:40:00
AM ADMIN
Afternoon
Check In Physician Type12:45:00
PM 1:00:00 PM ACUT
1:00:00 PM 1:20:00 AM ACUT
1:20:00 PM 1:40:00 AM ACUT
1:40:00 PM 2:00:00 PM ACUT
2:00:00 PM 2:20:00 PM EST
2:20:00 PM 2:40:00 PM ACUT
2:40:00 PM 3:00:00 PM EST
3:00:00 PM 3:20:00 PM ACUT
3:20:00 PM 3:40:00 PM ADD-ON
3:40:00 PM 4:00:00 PM ADD-ON
4:00:00 PM 4:20:00 PM ADMIN
4:20:00 PM 4:40:00 PM ADMIN16
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Typical Navy Med Home Port Team
17
Equivalent to 4 providers
(not bodies)
3 clerks
10 medical assistants
2 nurses
C-FTE
0.5 RN/c-FTE
2.5 CMA/c-FTE
0.75 clerk/c-FTE
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Fleet Centered Med Home Team
18
Equivalent to 4 providers
(not bodies)
1-3 clerks
~10 HMs
1RN & 1 LPN& 1 Care Coord.
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FCMH Test Sites
• Cherry Point (Marine Air)• Camp Lejeune (Marine Logistics
Regiment) • Gulfport (Seabees)• NAS North Island (Navy Air)• NAS Whidby Island (Navy Air) • Camp Pendleton (Marine Infantry)• Okinawa (Marines @ Kinser / Hansen)
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A Redesigned Workflow Better Leverages FCMH Team
Members
Preventive MedicineChronic Disease Monitoring
Medication RefillsAcute CareTest Results
Provider
Case Manager
Behavioral Health
CorpsmenNursing?
Provider
Patient
Behavioral Health
Corpsman
Nurse
Chronic Disease
Monitoring
Managed
Tracking
Preventative Care
Acute Care
Chronic Disease
Compliance
Acute Mental Health
Care Coordinati
on
Test Results
Traditional Workflow: Provider-Centered
Future Workflow: Team-Based Approach
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First three tabs are for ancillary nursing staff
Yellow means copy forward
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Workflow Research Results JC/HSI
23
Pain
Alcoho
l
Tobac
co
Med
icatio
nPM
H
Allerg
ies
Family
Hist
ory
Surge
ry H
istor
y
OTC vita
min
supp
Lear
ning
Disabil
ity
Deploy
men
t rela
ted
Anti-d
epre
ssan
t/suic
ide
Avera
ge c
ompli
ance
%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PRE-COMPASS %
POST-COMPASS %
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Workflow Research Results RVU’s
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Provider Entered Corrected
RVU per encounter (Staff)
Pre Compass Staff Post Compass Staff
0.972 1.269 1.054 1.241
Provider Entered Corrected
RVU per encounter (Intern)
Pre Compass Intern Post Compass Intern
0.943 0.971 1.067 1.045
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Workflow Research Results Coding Accuracy
25
Pre-Compass Staff Pre-Compass Interns Post-Compass Staff Post-Compass Interns 0%
10%
20%
30%
40%
50%
60%
70%
80%
Coding Accuracy
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Anticipated Effects of FCMH
Access to Care
Team continuity
PCM continuity
Patient satisfaction
Improved:Reduced Cost of Care:Unnecessary:
ER use
Network care
Ancillary tests
Hospitalizations
Specialty visits
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Decreasing Purchased Care
• Largest area to make significant progress is in Emergency Room use for primary care
• Top 10 ICD codes seen by AD in ER are not emergent
• Exponential growth of costs• Goal is to bring them back into Navy
Medicine facilities• Means more fuel, aircraft and ships for
CNO if we can reduce our inflation
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Monitoring FCMH performanceExperience of Care
• FCMH Team Continuity• PCM Continuity• 3rd Next Available
Acute/Routine• Patient Satisfaction
Per Capita Cost• % kept consult appts• ER Utilization
Readiness• Indeterminate• Partially Medically Ready• PHA completion rate• Immunization
compliance• New metrics may be added, if mutually agreed upon
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Marine-Centered Medical Home(MCMH)
Metrics – Annual Review
2013 - 2014
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Background
• The Marine Centered Medical Home (MCMH) is a federated effort by USMC and Navy Medicine to EFFECTIVELY deliver high quality medical care to operational Marines in appropriate garrison medical facilities.
• MCMH is a comprehensive USMC garrison care construct modeled after similar Navy Medicine and civilian sector approaches – while respecting USMC-specific prerogatives.– One standard of care across Department of the Navy.– Enhanced access to and quality of care.– Integration with Navy Medical Neighborhood (IT, Sports
Medicine, Behavioral Health, Ancillary support, etc.).
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Background
• MCMH Master Plan:– Six (6) pilot sites initiated 23Jan2013.– Expand to 17 more sites in FY15.– A final eight (8) sites require MILCON.
• 29 Palms estimated complete in late FY14/early FY15.• Kaneohe Bay construction scheduled to start in FY16.• Six (6) other sites require new construction or expansion to meet
final requirements.
• Behavioral Health Integration Program (BHIP)– Separate DoD program embedding Behavioral Health
provider in primary care clinics.– HQMC (HS) and BUMED have linked this program directly
to MCMH.
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Enrollment
BLUF• MCMH Enrollment efforts began in January 2013. By April
2013 4,300 Marines were enrolled in a MCMH • Through the remainder of FY13, MCMH enrollment notably
grew nearly 40% each month to a peak enrollment of ~ 27K one year later in January 2014
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13Jul-1
3
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
0
5000
10000
15000
20000
25000
30000
Total Enrollment
Total Enrollment
Source: BUMED M3B7 - Data Source: MHS Mart (M2) May 2014
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MCMH Enrollment By Quarter
MCMH French Creek MCMH Cherry Point MCMH 62 Area-San Mateo
MCMH Camp Hansen MCMH Camp Kinser MCMH MCAS Miramar0
1000
2000
3000
4000
5000
6000
7000
8000
FY13Q2 FY13Q3 FY13Q4 FY14Q1 FY14Q2
3.4K
7.4K
4.3K
3.7K
1.7K
6.1K
FY14 Q1 & Q2 Average
Enrollment 26.3K
Source: BUMED M3B7 - Data Source: MHS Mart (M2) May 2014
Nu
mb
er
of
MC
MH
En
rolled
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Emergency Room Utilization
BLUF• During CY13, MCMH enrollees had a direct care
(MTF) ED utilization rate 53% lower than OPFOR Marines and 36% lower than Marines enrolled to non-MCMH clinics
• During the same period, MCMH enrollees had 33% fewer Purchased Care (civilian care) ED visits compared to OPFOR Marines and 57% fewer than non-MCMH enrolled
• Overall cost avoidance exceeds $5 MIL
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ER Utilization per 100 EnrolleesDirect Care and Purchased Care
CY2013
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
26.524.8 25.1
9.5
26.1
101.4
14.5
22.5
28.4
10.5
15.0
29.9
21.9
15.1
32.4
37.6
14.2
28.2 27.9
↑101.4
Source: Navy and Marine Corps Public Health Center, Health Analysis Department- Data Source: MHS Mart (M2) March 2014Enrollee population includes only active duty Marines
Down is good!Target < 30
ER
Vis
its p
er
10
0 E
nro
lled
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Team Continuity
BLUF• April 2013-March 2014 MCMH enrollees were seen
by their Primary Care Manager (PCM) or a provider within their Primary Care Team 85% of the time– During this same period, Team Continuity at the nearby
MTFs averaged 92% (not inclusive to only Marines but includes appointments for all beneficiaries) and Navy Medicine’s total Team Continuity rate was 95%
Team Continuity data does not provide the same level of detail as other data sources. Therefore, comparisons to OPFOR enrolled are not possible. Instead, comparisons were made for all enrolled beneficiary types at the Parent
MTF and the Navy overall.
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Team ContinuityApr 2013 – Mar 2014
MCMH Fren
ch Cree
k
NH CAMP LEJEU
NE
MCMH Cherry P
oint Tea
m 1
MCMH Cherry P
oint Tea
m 2
NHC CHERRY P
OINT
MCMH 62 Area-Sa
n Mate
o
NH CAMP PENDLET
ON
MCMH Camp Han
sen
MCMH Camp Kinser
NH OKINAW
A
MCMH MCAS M
iramar
Team
1
MCMH MCAS M
iramar
Team
2
NMC SAN DIEG
O
MCMH Total
MTF To
tal
Navy T
otal0%
20%
40%
60%
80%
100%
120%
82%
91%
100% 100% 99%
75%
91%
71%
55%
89%
100% 100%
92%85%
92% 95%
Source: BUMED M3B7- Data Source: TRICARE Operations Center (TOC) April 2014
Up is good!
% T
eam
Con
tin
uit
y
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Access to Care
BLUF• In the early stages of MCMH implementation,
FY13 Q3 and Q4, access to care results were mixed
• However, the practices matured significantly and in FY14 Q1 and Q2, access to care for MCMH Enrollees, as measured by time-to the next available (open) appointment, is 15% less (better) than enrollees at proximate MTFs and 5% less than the time-to access for the entire Navy
Access to care data does not provide the same level of detail as other data sources. Therefore, comparisons to OPFOR enrolled are not possible. Instead, comparisons were made for all beneficiary types at the Parent MTF and
the Navy overall.
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MCMH Fren
ch Cree
k
NH CAMP LEJEU
NE
MCMH Cherry P
oint Tea
m 1
MCMH Cherry P
oint Tea
m 2
NHC CHERRY P
OINT
MCMH 62 Area-Sa
n Mate
o
NH CAMP PENDLET
ON
MCMH Camp Han
sen
MCMH Camp Kinser
NH OKINAW
A
MCMH MCAS M
iramar
Team
1
MCMH MCAS M
iramar
Team
2
NMC SAN DIEG
O
MCMH Total
MTF To
tal
Navy T
otal0.00
0.50
1.00
1.50
2.00
2.50
0.70
1.45
1.00 0.95 0.95
0.55
0.90
0.60 0.60
0.80
2.25
5.55
1.401.53
1.01 0.95
Access to Acute CareDays-to 3rd Next Available Appointment
Early Period Apr 2013 – Sep 2013
Days-t
o 3
rd N
ext
Availab
le
Acu
te
↑5.6
Source: BUMED M3B7- Data Source: TRICARE Operations Center (TOC) April 2014
Down is good!Target < 0.5 Days
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MCMH Fren
ch Cree
k
NH CAMP LEJEU
NE
MCMH Cherry P
oint Tea
m 1
MCMH Cherry P
oint Tea
m 2
NHC CHERRY P
OINT
MCMH 62 Area-Sa
n Mate
o
NH CAMP PENDLET
ON
MCMH Camp Han
sen
MCMH Camp Kinser
NH OKINAW
A
MCMH MCAS M
iramar
Team
1
MCMH MCAS M
iramar
Team
2
NMC SAN DIEG
O
MCMH Total
MTF To
tal
Navy T
otal0.00
0.50
1.00
1.50
2.00
2.50
0.75
1.35
1.001.10
0.800.70
0.850.75
0.60
0.800.70
1.25 1.25
0.861.01
0.90
Access to Acute CareDays-to 3rd Next Available Appointment
MaturingOct 2013 – Mar 2013
Days-t
o 3
rd N
ext
Availab
le
Acu
te
Source: BUMED M3B7- Data Source: TRICARE Operations Center (TOC) April 2014
Down is good!Target < 0.5 Days
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Referral Appointments Kept
BLUF• Since January 2013, each of the MCMH sites
demonstrated a higher percentage of kept referral appointments and shorter median wait times for a referral appointment in comparison to OPFOR Marines and most non-MCMH Marines enrolled to local MTFs
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Referral Appointments KeptJan 2013 – Mar 2014
Up is good!
Source: Navy and Marine Corps Public Health Center, Health Analysis Department- Data Source: MHS Mart (M2) March 2014Enrollee population includes only active duty Marines
An initial referral can have several appointments associated with that referral (e.g., a series of mental health clinic appointments); all appointments associated with an initial referral were maintained for these analyses
% o
f R
efe
rral A
pp
oin
tmen
t K
ep
t
MCMH Fren
ch Cree
k
AD NH Camp Le
jeune
OPFOR NH Cam
p Lejeu
ne
MCMH Cherry P
oint
AD NHC Cherry P
oint
OPFOR NHC Cherr
y Point
MCMH Camp Han
sen
MCMH Camp Kinser
AD NH Okin
awa
OPFOR NH O
kinaw
a
MCMH 62 Area-Sa
n Mate
o
AD NH Camp Pen
dleton
OPFOR Cam
p Pendlet
on
MCMH MCAS M
iramar
AD NMC San Dieg
o
OPFOR NMC Sa
n Diego
MCMH Total
AD MTF
Total
OPFOR To
tal60%
62%
64%
66%
68%
70%
72%
74%
76%
78%
80%
0.756
0.722
0.698
0.7825
0.7640.772
0.724
0.752 0.750.742
0.6860.6860.674
0.732
0.704
0.718
0.73875
0.72520.7208
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Average Days-to Referral Appointment
BLUF• Since January 2013, the average days it takes to
obtain a specialty consultation appointment for MCMH enrollees is 21% faster than Marines enrolled to proximate MTFs and 33% faster than OPFOR enrolled Marines
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MCMH Fren
ch Cree
k
AD NH Camp Le
jeune
OPFOR NH Cam
p Lejeu
ne
MCMH Cherry P
oint
AD NHC Cherry P
oint
OPFOR NHC Cherr
y Point
MCMH 62 Area
-San M
ateo
AD NH Camp Pen
dleton
OPFOR Cam
p Pendlet
on
MCMH Camp Han
sen
MCMH Camp Kinser
AD NH Okin
awa
OPFOR NH O
kinaw
a
MCMH MCAS M
iramar
AD NMC San Dieg
o
OPFOR NMC Sa
n Diego
MCMH Total
AD MTF
Total
OPFOR To
tal0
2
4
6
8
10
12
14
5.2
7.2
8.6
5.75
3.8
6.2
7.4
10
12.4
3.2
1.4
3.63.2
7 7.2 7
4.99166666666667
6.36
7.48
Average Days-to Referral AppointmentJan 2013 – Mar 2014
Down is good!
Source: Navy and Marine Corps Public Health Center, Health Analysis Department- Data Source: MHS Mart (M2) March 2014Enrollee population includes only active duty Marines
An initial referral can have several appointments associated with that referral (e.g., a series of mental health clinic appointments); all appointments associated with an initial referral were maintained for these analyses
Average days to referral appointment is defined as the median number of
days from scheduling to completion of a kept referral appointment
Avera
ge D
ays t
o R
efe
rral
Ap
pt
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Medical ReadinessBLUF• Since MCMH implementation, the average
number of Marines not medically ready to deploy has decreased by 22%.
• Additionally, the number of fully medically ready Marines has increased by 3% since implementation and is maintaining at >82%
Source: MRRS; Non-Deployed IMR Reports Feb 2013 – May 2014
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Key Points• Nearly 27K Marines are enrolled in a MCMH• Controlling costs: In CY2013 ED utilization rates were ½ that
of Marines enrolled to nearby MTFs and ½ of OPFOR enrolled Marines for a net cost avoidance of $5MIL
• Maintaining continuity: MCMH enrollees see a member of their primary care team 85% of the time
• Improving Access: MCMH enrollees have 15% greater access to same day appointments compared to Marines at nearby MTFs and 5% greater access compared to the entire Navy.
• Coordinating Care: MCMH enrollees have a higher % of kept referral appointments and shorter wait times for their appointments
• Improving Readiness: Enrolled units are maintaining >82% Fully Medically Ready status (a 3% improvement) and maintaining <6.5% Not Medically Ready (a 22% improvement).
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FCMH Leadership*
• FCMH transformation is an organization-level change initiativeo To be successful, leaders must provide active,
continuous supporto Instill confidence and enthusiasm for this challenging
transformationo Provide motivation for continuous improvement and
innovationo Provide support for their staff as practice teams
redesign themselves and their processes to provide better quality, more accessible, and more patient-centered care
*Leadership includes CO, XO 47
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“If you don't like change, you're going to like
irrelevance even less.”- General Eric Shinseki (ret.)
Former Chief of Staff, U.S. Army
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Summing It Up for Navy Medicine
• Familiar source of care = safe, quality care• Small teams can provide coverage• Care must be coordinated; accountable team• Proactive, not reactive healthcare• Documentation of care in electronic record
critical• Quality improvement activities crucial• Evidenced based decision support• Ready access to care with team; use of ER
only when appropriate
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Questions?