When Army major and family physician Julie Hundertmark, M.D., started working in 2005 as a resident at a family medicine clinic in Fort Benning, Ga., she often felt as though she was practicing alone, isolated from her physician colleagues and other members of the health care team.
"I was truly an island of one," says Hundertmark, who still practices at the same Fort Benning clinic. "Everything depended on the physician, as far as getting anything done." Although Hundertmark had nursing staff support, she did not feel as though she had "a nursing staff that supported me individually as a physician."
In 2009, however, the Army chose the clinic Hundertmark works at as one of its first patient-centered medical home (PCMH) sites. The clinic began implementing the PCMH model in July 2009, and patient care at the clinic began to change, according to Hundertmark. It became much more integrated and coordinated, allowing the clinic to deliver a higher level of care to its patient population.
"It has made such a difference in my personal practice with my own personal patients," says Hundertmark. "My work hours have changed. I am actually able to leave much earlier than I used to because I have other members of the health care team who are helping with the documentation and helping me to track things, like quality measures."
Hundertmark notes that all of the activities are done under her supervision, but before the PCMH model, she was responsible for contacting her patients and determining where they were with their prescription refills or how their care fared in relation to quality metrics. "Now that we have rolled out the medical home, I can truly say I love working in my clinic because of the team concept," says Hundertmark.
- The nation's armed forces and the U.S. Department of Veterans Affairs (VA) have emerged as a major force for transformation to the patient-centered medical home (PCMH) model of care during the past few years.
- The Army, Navy, Air Force and VA are in the process of transforming thousands of practices to PCMHs, which will impact millions of patients.
- Use of the PCMH by the military and the VA has created a synergy between the military and civilian worlds, allowing each to learn from the other and accelerating PCMH initiatives in both the civilian and military sectors.
Hundertmark is part of a growing PCMH movement that is sweeping through the military and the U.S. Department of Veterans Affairs (VA). It is transforming thousands of practices and bringing millions of patients into the medical home model.
The VA's Veterans Health Administration (VHA), along with the Army, Navy and Air Force, has embraced the PCMH model, using it to focus health care systems on team-based, patient-centered care. In the process, the VHA and the various branches of the military have emerged as a major force for PCMH transformation that is rivaling and, in some cases, surpassing PCMH efforts in the private sector.
Many military officials say they turned to the PCMH model out of necessity and a genuine desire to improve health care for their patients. "We were not taking care of our patients as well as we could have been," says Lt. Col. Timothy Kosmatka, M.D., a family physician who serves as Air Force chief consultant for family medicine services. "We had not achieved the levels of continuity from a patient perspective that we know drive positive outcomes."
The same was true of individual physicians and other health care professionals, too, he notes. "Our physicians were feeling overworked because most of the work was falling to the (physicians)," says Kosmatka. "We really felt that we needed to make a change to the medical home mind-set in really emphasizing team-based care and really using people to the maximal extent of their licensure and skill set."
"I have been in the VA for 30 years, and I remember what it used to be like," says Richard Stark, M.D., director of primary care clinic operations for the VA. "To see the changes that we have been able to make in these last couple of years is pretty amazing. When I talk to the folks out in the field about their views of this, they say, 'This is why I went into medicine' or 'This is the way I always wanted to practice.'"
TransforMED, the AAFP's wholly owned, nonprofit subsidiary, has served as an unofficial consultant on the patient-centered medical home (PCMH) model for all branches of the military during the past three years.
In this capacity, TransforMED shares its expertise on the PCMH with military personnel through military-convened panels and meetings.
"We also have conducted small PCMH projects for the military," says Terry McGeeney, M.D., president and CEO of TransforMED. "For example, we have done physician leadership training for the Navy on the PCMH."
TransforMED recently joined with PricewaterhouseCoopers to support a PCMH initiative within the Army's Northern Region Command that will essentially transform outpatient clinics at 15 northeastern Army bases into PCMHs. This represents TransforMED's biggest project yet with the military.
"It is basically a train-the-trainer type of program where TransforMED will be training military staff to implement the medical home attributes in their outpatient clinics," says McGeeney.
McGeeney is convinced that the military's adoption and use of the PCMH makes "perfect sense," explaining that the military takes care of a diverse population across a wide geographic area that would benefit greatly from a strong primary care infrastructure and the PCMH.
Not surprisingly, McGeeney equates the military's commitment to the PCMH with their dedication and commitment to primary care. "That is the reason TransforMED is so interested in being involved in this," McGeeney says.
The VHA provides care to about 8 million beneficiaries, and furnishes primary care services to about 5.2 million of those beneficiaries, according to Stark. It is the largest integrated health care system in the country.
During the past 18 months, the VHA has been converting its 1,000 primary care practice sites to the PCMH model, and Stark is convinced that the PCMH model prevents hospitalizations and emergency room visits while helping patients manage their own care. As proof, he cites statistics showing that urgent care visits by patients enrolled in VHA primary care facilities decreased by 8 percent after rollout of the PCMH model in 2011. In addition, the VA experienced a 4 percent decrease in acute admission rates to VHA facilities in 2011.
These statistics have real relevance for individual VHA clinics. Gustavo Garcia-Ramos, M.D., is a family physician who has practiced within the VHA system for nearly 10 years, well before his VHA clinic started implementing the PCMH.
According to Garcia-Ramos, the PCMH has resulted in faster and better access to care at the South Bexar Clinic in San Antonio, where he practices. Ramos also cites the efficiency of health care teams as another benefit of the PCMH.
The experiences of Garcia-Ramos and others at the VHA are shared by the branches of the military that have adopted the PCMH model. For example, the Air Force has seen a 14 percent reduction in emergency room and urgent care visits during the past six months as a result of the PCMH, according to Kosmatka.
The Air Force began implementing the PCMH model in 2008, starting with its family physician health clinics. "We have 75 of those across the globe," says Kosmatka. "As of Feb. 1 of this year, all of our family health clinics are practicing in a patient-centered medical home construct."
In 2011, the Air Force started to expand the PCMH model to its pediatric clinics and will have all of them practicing within the PCMH model by May, says Kosmatka. In addition, the Air Force plans to extend the PCMH model to its internal medicine clinics this year.
In implementing the PCMH, the Air Force developed health care teams made up of eight personnel: one physician, a midlevel health care professional, a nurse and five medical technicians. In nearly every case, the physician leads the health care team, and each team has a patient panel that includes about 2,500 patients, according to Kosmatka.
The Army, meanwhile, has followed a similar path to PCMH adoption by assembling physician-led health care teams to deliver patient-centered care. Like the other branches of the military, the Army has targeted its primary care group -- family medicine, pediatrics and internal medicine -- for PCMH transformation.
Thus far, the Army has transformed 157 practices into PCMHs, and, according to Col. Mark Reeves, M.D., a family physician who serves as the Army's family medicine consultant, it expects that number to grow to about 250 during the next two to three years.
Not surprisingly, the military's adoption and use of the PCMH have prompted comparisons with PCMH efforts in the private sector. In many ways, the military is confronting the same challenges with the PCMH that exist in the civilian world.
If nothing else, the PCMH represents a profound cultural change that is not easy for everyone to adapt to or even accept. "There are many who are skeptical about the medical home," says Reeves. "But we are trying to show them the merits and bring them over."
The various branches of the military also have some inherent advantages and disadvantages when it comes to implementing the PCMH. The government provides the military with a set budget, and, as a consequence, the military essentially operates within a capitated payment system. This type of payment structure is much more conducive to the PCMH model than the prevailing fee-for-service payment structure that exists in the private sector.
"It also is an opportunity for a modified reward system, such as the Army's Performance-based Adjustment Model, which rewards leaders and staff for achieving benchmarks in continuity, patient satisfaction, health promotions and administrative efficiencies," says Reeves.
But at the same time, people transition in and out of the military on a regular basis, making retention of personnel much more difficult than in the civilian sector. "Our greatest challenge with the medical home will be to sustain it," says Kosmatka.
Military officials are convinced, however, that their use of the PCMH model is creating a type of synergy between the military and civilian worlds, allowing each to learn from the other. This, in turn, is expected to accelerate PCMH initiatives in both the civilian and military sectors. For example, Kosmatka notes that the Air Force has an excellent electronic medical records system, one that the civilian sector can learn from.
"It is not only a nationwide electronic medical record, it is a worldwide electronic medical record," says Kosmatka. "That ready access to information really helps with disease management and care coordination."