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