Mind the Gap…Integrating Public Health and Health Care in a Military Population

Theresa Casey, DVM, MPH, ACVPMBrigadier General (ret), USAF

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Overview

• Military necessity• Organization supports integration • Integration in clinical care• Successes/consequences• Integration in All Hazards incidents

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Military Necessity

• Tactical/strategic impact of infectious disease

• Camp/personal sanitation• Chronic disease • Enlistment standards• Mental health

If you are careful of your men, and camp on hard ground, the army will be free from disease of every kind and this will spell victory.

BehavioralChronicInfectious

Military Public Health

Integration critical to recruiting and maintaining a fit forceWWII experience demonstrated clinical and preventive medicine must work in close coordination in establishing standards

Spanish-American War

Dodge Commission Report, 1899• Civilian physicians unprepared to

oversee camp sanitation• Training/discipline essential in

preserving health in garrison/field• Military medicine/hygiene training is

essential • Preparation key, "In time of peace

prepare for war”• Army medicine reorganized to improve

medical care/preventive medicine

Organization/Governance

• Organization includes prevention/wellness • Dedicated staffing assigned • Vision, values, mission statement • Governance and accountability

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Organization

Commander/CEO

Dental Operations

Medical Operations

Chief Operations OfficerChief , Medical StaffChief Nurse ExecutiveChief, Aerospace Medicine

Medical Support

Operations

Aerospace Medicine

Primary careSpecialty careCommunity healthIndividual wellnessOccupational healthDisease pv/control

Primary careSpecialty careBehavioral healthFamily advocacySubstance abuse pv

Quality/CredentialsPatient Safety

Public Health Staffing

Public Health OfficersBioenvironmental EngineersMedical EntomologistsSocial WorkersClinical PsychologistsDieticians

Integration from the Top

Stakeholders Report

Operation

Re-Deployment

Retirement/Separation &Beyond

Operational Health& Surveillance

Post-Deployment

Deployment

Pre-Deployment

Health & Wellness

Direct Care

Preventive Medicine

TRICARE

Family Support

Health Education

MentalHealth

Career Health& Surveillance

TrainingDuty

Prevention forForce Protection

Prevention for Force Enhancement & Peacetime Benefit

Accession

Human Weapon SystemLife Cycle Vision

Pilot

Integrated Prevention

Primary Prevention

• Community• Food safety, vulnerability• Environmental, workplace, community surveillance• Vector surveillance/control• No-smoking installations

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Primary Prevention

• Individual• Consequence-based fitness testing• Health and Wellness Centers• Family Advocacy parenting instruction/consultation

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Integrated Prevention

Clinical Prevention

• Primary• Immunizations• Smoking cessation

• Secondary• Pre-deployment assessments• Occupational exams• Disease screening• Clinical practice guidelines• Behavioral Health Optimization

• Tertiary• Clinical practice guidelines• Specialty care

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VA/DoD CPGsAsthmaChronic Heart FailureChronic Kidney DiseaseCOPDDiabetes MellitusDyslipidemiaHypertensionIschemic Heart DiseaseObesity and OverweightTobacco Use

Bipolar Disorder in AdultsMajor Depressive DisorderPost Traumatic Stress DisorderSubstance Use DisorderSuicide Risk Assessment/Mgt

Opioid Therapy for Chronic PainLower Back PainPost-Operative Pain

Concussion-mTBILower Limb AmputationStroke RehabilitationLower Back PainPost-Operative Pain

Foster integration of evidence-based practice into VA/DoD initiatives related to health promotion, disease prevention and wellness initiatives

PATIENT EXPERIENE

Our Foundation is the PCMH Healthcare Team

PATIENT

AF Medical Home

QUALITYMEASURES

AIR FORCEMEDICAL HOME

PATIENT EXPERIENCE

PHYSICIAN‐ledTEAM

INFORMATIONMANAGEMENT& TECHNOLOGY

Social Media

Shift from Healthcare to Health in the AF Medical Home

Virtual CareBalance

RSV Training

(Readiness)

Decision Support & Knowledge

Mgmt (IM/IT)

ProcessPracticeVariation

(GPM)

Health Plan Mgmt

(TOPA)

Broadly refers to an individual’s ability to manage his or her

health or healthcare

Patient ActivationWhat is Patient Activation?

Sources: http://www.insigniahealth.com/docs/Rel_MI_PA.pdfhttp://www.insigniahealth.com/products/pam.html

Building RAPPORT Through Teamwork And Patient Activation

Building Knowledge& ConfidenceLevel 2

Starting To Take A RoleLevel 1

Taking ActionLevel 3

MaintainingBehaviorsLevel 4

Incr

easi

ng A

ctiv

atio

n

Developed by Dr. Judy Hibbard and colleagues13 questions categorized under the four domains

Patient Activation Measure (PAM)

Patient Activation

Sure, but can you make him drink?

HEDIS Metrics

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Successes

• Smoking among recruits• Seat belt use is high• Childhood immunizations high• Responsible alcohol use…but abuse persists• HIV prevention and control

Unintended Consequences

• Submaximal cycle ergometryfitness testing

• Fitness testing abdominal circumference/taping

• 1½ mile run fitness criteria• Occupational injury reporting

incentives • Influenza immunization rate

incentives

e-Health Transformation

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ACTIVITIES

TIMELINE (FY)

2012 2013 2014 2015

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Tri-Service Workflow

Feb 12: Training of LBP CPG in MTF'sApr 12; Deploy Metabolic Syndrome CPGFall 12: Deploy Behavioral Health Workflow

CarePoint and HSDW

Jun: Launch CarePoint into ProductionSep: Publish Hospital Dashboards Oct: AFRESS AvailableFuture: Incorporate Other Apps

Virtual Medical Center (VMC)

Dec 11: Prioritized List of Future Virtual ClinicsApril 12: Ortho & Cardio Validation – SGROCDec 12: DVC; Full Op Capability (FOC)Mar 13: Ortho & Cardio FOC

Secure Messaging/PHR

Nov 11; Wave Deployment BeganJun 12: 26 MTFs CompleteApr 13: Deployment Complete

iEHR

iEHR Rolled Out in Capability Sets

1

2

3

4

5Set 5-8Capability Set 1 Set 2 Set 3 Set 4

Phase 2Phase 1

Social Networking Creates the Buzz to Make Messages Stick

26AF Medical Service Exploiting New Avenues of Communication

All Hazards Public Health

• Deploying member• Pre-deployment screening• Camp sanitation• Immunizations/prophylaxis

• Mission requirements • War versus humanitarian• Tailor to event/population

Summary

• Military necessity• Organization supports integration

• Integration in clinical care• Successes/consequences• Integration in All Hazards incidents

Questions

Genomics in Individual Health

• Family history current surrogate for genetic testing

• Improves prediction of disease • Targets screening and

prevention• Genetic testing supplements,

not supplants family history• Improved disease management

• Rare diseases• Cancer

• Point-of-care testing emerging• Diagnostics• Pharmacogenomics