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ARMY PCMH Implementation Manual 10 Leaders Guide to Army Patient Centered Medical Home Transformation 11

12 13 14 15 16 17 18 19 20 21 US Army Medical Command 22 15 January 2013 23 24 25 26 27 28 29

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Executive Summary 38

Patient Centered Medical Home (PCMH) is the foundation of health and readiness for all our 39 beneficiaries and will be the key for transformation from a healthcare system to a system for 40 health. Timely implementation is essential for our strategic success. 41

The PCMH Implementation Manual establishes the standards and methods for initial 42 implementation of the Army PCMH model. The Operations Manual will describe the quality, 43 responsive, and comprehensive care we provide as a more patient centered system for 44 health. 45

Implementation is divided into two phases. During the preparation phase a leadership team 46 (guiding coalition) is assembled, leaders share the vision with their organization, a standard 47 readiness assessment is completed in which personnel, process, equipment, training 48 requirements are identified. During the recognition phase, practices receive approval to 49 enter the NCQA recognition process, the PCMH practice multi-disciplinary team is assembled 50 and trained to work together utilizing proven processes and key enablers such as MAPS 2.0, 51 secure messaging, service recovery matrix, etc. Successful completion of the recognition 52 phase is marked by an officially validated PCMH practice which has achieved a minimum 53 state of readiness, level II or higher NCQA recognition, and completed the region led staff 54 assessment visit. Once validated the practice will continue to improve and refine the 55 processes, incorporate advanced practices, gain efficiency, and achieve better health and 56 readiness outcomes. Our patients will be active partners, our staff more empowered and 57 integrated, care will be seamlessly coordinated, systems will be aligned resulting in a 58 consistent, quality experience and ultimately better health for those we serve. 59

Army Medicine, indeed US healthcare, is at a cross roads. PCMH will set our true north and 60 establish the irreversible momentum we need to continually improve readiness, resilience, 61 and ensure we are the health system of choice for all our beneficiaries. Our Nation depends 62 on our ability to improve the health of those that have worn and continue to wear the cloth of 63 our Nation and the Families that support them. PCMH will serve as the foundation to 64 ensuring the ultimate patient care experience and serve as the bridge to our patients’ health 65 decisions being made in the Lifespace. 66

Serving to Heal…Honored to Serve! 67 68 69

Donna A. Brock Patricia D. Horoho 70 Command Sergeant Major, US Army Lieutenant General, United States Army 71 US Army Medical Command The Surgeon General and 72 Commanding General, 73

US Army Medical Command 74 75

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TABLE OF CONTENTS 76 77

Page 78 79 CALL TO ACTION....................................................................................... 2 80 81 CHAPTER ONE – INTRODUCTION………………………………………...... 4 82 83 1-1. Purpose………………………………………………………………... 4 84 85 1-2. Vision…………………………………………………………………... 5 86 87 1-3. Mission.......................................................................................... 5 88 89 CHAPTER TWO – ARMY PCMH IMPLEMENTATION…………………….. 6 90 91 2-1. Phase I: Prepare………………………………………………........ 6 92 93 2-2. Phase II: Recognize………………………………………………… 12 94 95 2-3. Phase III: Perform…………………………………………………... 15 96 97 CHAPTER THREE – PCMH ROLES AND RESPONSIBILITIES……........ 17 98 99 3-1. Accountable Care Organization…………………………………….. 17 100 101 3-2. PCMH Staff Model……………………………………………………. 18 102 103 3-3. Medical Neighborhood……………………………………………….. 18 104 105 APPENDIX A – REFERENCES................................................................... 21 106 107 GLOSSARY…………………………………………………………………....... 22 108 109 Section I – Abbreviations…………………………………………………… 22 110 111 Section II – Terms.................................................................................. 25 112 113 FEEDBACK AND IMPROVEMENTS.......................................................... 29 114 115

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CHAPTER ONE 119 INTRODUCTION 120

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1-1. Purpose 123 124 Transformation from a healthcare system to a System For Health begins with 125 transformation of our system of primary care. This renewal of primary care improves our 126 ability to prevent disease and enhance wellness, manage chronic disease, and deliver 127 comprehensive care through empowered teams. We transition from fragmented, 128 uncoordinated care to comprehensive, collaborative care. We enable patient growth from 129 passive recipient to active partner in the journey to health. 130 131 We call this transformed model of primary care a Patient Centered Medical Home 132 (PCMH). The Army has developed a standard PCMH implementation model called the 133 Army PCMH. This model applies to all primary care platforms including Soldier Centered 134 Medical Homes (SCMHs) and Community Based Medical Homes (CBMHs). 135 136 This Implementation Manual defines the standard methods and processes for 137 implementation of the Army PCMH model. It is written for leaders at all levels of the 138 organization: practice, department, military treatment facility (MTF), and regional medical 139 command (RMC). It assumes leader engagement and commitment to transformation. 140 141 At end state, Army PCMHs will-- 142

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• Deliver a high quality and consistent patient experience that inspires our 143 beneficiaries to choose Army Medicine. 144

• Minimize unwarranted variance and improve operating efficiency and 145 effectiveness. 146

• Build capacity in the direct care system. 147 • Serve as a platform for achieving our strategic imperatives: create capacity, 148

enhance diplomacy, and improve stamina. 149 • Extend our influence in the Lifespace in order to invigorate the Performance Triad: 150

activity, nutrition, and sleep. 151 152 Army PCMH also serves as an integrating function in Army Medicine. Army PCMH is the 153 common platform through which related initiatives are synchronized and integrated. 154 155 1-2. Vision 156 157 Inspire life-long positive changes in our beneficiary’s health through Army Medicine’s 158 transformation from a healthcare system to a patient-centered System For Health. 159 160 1-3. Mission 161 162 Build the premier patient-centered, team-based, comprehensive System For Health that 163 improves readiness and promotes health. 164

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CHAPTER TWO 165 ARMY PCMH IMPLEMENTATION 166

167 The Implementation Roadmap (fig 2) defines the phases and critical tasks required to 168 implement and operate the Army PCMH. Tasks can run sequentially and concurrently 169 within each phase. Tasks such as readiness assessment, gap analysis, and training are 170 ongoing activities that are dynamic in nature and require constant review and adjustment 171 over time. Implementation ends at the completion of phase II. A practice will receive 172 Medical Home status when it meets three criteria: 1) practice readiness assessment 173 score of 7.5 or greater, 2) National Committee for Quality Assurance (NCQA) recognition 174 level 2 or higher, and 3) satisfactory staff assessment visit (SAV) utilizing the 175 Transformation Assessment Tool. The MTF and RMC will be expected to report 176 implementation progress and performance on a regular basis as specific in OPORD 177 11-20 and associated FRAGOs. 178 179

Figure 2. Implementation Roadmap 180 181

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2-1. Phase 1: Prepare 184 185 Preparation involves all pre-implementation tasks and activities required to ready the 186 PCMH practice(s) to receive NCQA recognition and operate as an Army PCMH. 187

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Preparation phase occurs prior to initiating the NCQA recognition process and should 188 take no longer than 180 days. The conversion to a standardized Medical Expense 189 Performance Reporting System (MEPRS) code begins in this phase and is critical to 190 performance measurement and accountability of financial and human resources in the 191 PCMH. 192 193 Task 1. Create a Guiding Coalition 194 195 The Guiding Coalition is the multidisciplinary team constituted and empowered to 196 implement the Army PCMH model across all primary sites under the authority of the MTF 197 commander. 198 199 Key characteristics of an effective Guiding Coalition include-- 200 201 Multidisciplinary. The Guiding Coalition will include primary care representation, along 202 with other sections, or departments that represent the Accountable Care Organization 203 (ACO). Membership includes, at a minimum-- 204

205 • Primary Care 206 • Specialty Care 207 • Managed Care 208 • Resource Management 209 • Facilities 210 • Referral Management 211 • Clinical Services 212 • Human Resources 213 • Public Affairs 214 • Information Management 215

216 Empowered. The MTF commander ensures that the Guiding Coalition is seen and 217 respected by others in the MTF so that the group’s decisions are effective. 218 219 Connected. The Guiding Coalition is the designated point of contact for communications 220 to and from the RMC. 221 222 Enduring. The work of the Guiding Coalition continues throughout the implementation 223 process. 224 225 Accountable. Members are accountable for the health of the patient and performance of 226 the practice. Accountability is formalized through written performance objectives that 227 support the organization’s goals. 228 229 NOTE: We refer frequently to the ACO in this manual. The ACO represents the MTF 230 leadership, all clinical and non-clinical support activities such as human resources, 231 information management, resource management, managed care, in addition to primary 232

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care, subspecialty, and surgical care lines. An ACO is unified in its responsibility for health 233 care and support to the same group of beneficiaries to achieve quality and stewardship 234 goals as an accountable, reliable, and effective System For Health organization. 235 236 Task 2. Communicate the Vision 237 238 Communication is an enduring leadership responsibility and must be accomplished 239 throughout the implementation and sustainment of the PCMH. MTF commanders and 240 leaders will use every opportunity to relay the vision and purpose of Army PCMH 241 transformation: emails, meetings, presentations. Effective communication supporting 242 transformation of this magnitude must be-- 243

• Simple and clear: Avoid jargon. 244 • Vivid: A verbal picture is worth a thousand words – use metaphor, analogy, 245

and example. 246 • Repeatable: Ideas should be infectious to be spread by anyone to anyone. 247 • Invitational: Two-way communication is always more powerful than one-way 248

communication. 249

Tools and messaging to support the commander’s communications campaign are located 250 at the PCMH Web site: https://www.us.army.mil/suite/page/661214. 251 252 Task 3. Conduct Baseline Readiness Assessment Using the PCMH Readiness 253 Assessment Criteria 254 255 The Readiness Assessment Criteria define the baseline from which a gap analysis is 256 developed. These standard criteria are reportable to MEDCOM and are scored as follows 257 and detailed in table 2: 258 259

• Red = 0 260 • Amber = 0.5 261 • Green = 1.0 262

263 The sum of all factors defines the overall level of readiness. A total of 7.5 points is the 264 minimum level to operate as a PCMH. Table 1 lists the red, amber, green criteria by focus 265 item. Each focus item is aligned with the implementation phase during which the MTFs 266 should become fully capable for that respective focus item. 267 268 Task 4. Perform Gap Analysis 269 270 The Readiness Assessment defines the baseline for the gap analysis. The Military Health 271 System (MHS) provides funds to the Army to hire primary care manager (PCM) support 272 staff for registered nurse (RN), licensed practical nurse (LPN)/medic, nurse’s aide (NA), 273 medical assistant (MA), medical support assistant (MSA), and the integrated behavioral 274 health consultant. For detailed explanation of the composition of the 3.1 support staff, see 275 MEDCOM PCMH FAQ: “What comprises the 3.1 staff ratio specified in the PCMH 276

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OPORD” at PCMH Web site: https://www.us.army.mil/suite/page/661214. Funding for 277 clinical pharmacists and dietitians is from core funds or through unfinanced requirement 278 (UFR) submission. 279 280

Table 1. PCMH Readiness Assessment Tool 281 282

PCMH Readiness Assessment Phase Scoring Criteria

Score (1 if green, .5 if Amber, 0 if red)

1. PCM Home Teams Phase 1

PCM Home Teams. (G=2-5 PCMs or all BDE PCMs/Home; A=>5 PCMs or BDE providers are split into two PCM home teams, R=No Teams)

2. Optimize Empanelment Phase 2

PCMs empanelled according to annex I, OPORD 11-20 (G-= +/- 5% max capacity, A= +/- 10% max capacity, R= more or less than 10% capacity; available clinical FTE must be validated by Commander or delegated surrogate

3. PCM Exam Rooms (2 min) Phase 2 PCM Exam Rooms. (G=2.0-3.0; A=1.8-<2.0; R=<1.8 FTE per

Provider FTE)

4. PCMH Team STEPPS Training Phase 2 Team STEPPS training complete (G=All 90-100%; A=>75%

75-89%;R=<50% <75% Staff)

5. AHLTA/MAPS Training & Infrastructure

Phase 2 AHLTA/MAPS2.0/Workflow (G=Phase III complete; A= Phase II complete, III partially complete; R=Phase II not complete; (phases defined in OPORD11-47 and in Strategic Management System)

6. RN Case Manager Support (incl Med Mng Cent and Respect-mil)

Phase 2 Nurse Case Manager (NCM). (G=1 per 6200 enrollees; A= 1 per 4500 or 8000 enrollees; R=1 per <4500 or >8000 enrollees)

7. PCM Support Staff (3.1 personnel)

Phase 2 PCM Core Support Team. (G=2.8-3.1 support staff; A=2.6-2.7 staff; R=<2.6 staff per Provider FTE)

8. Practice Manager Support Phase 2 Practice Manager (PM). (G=1 per 8-12K pts; A=1 per 12-17K

pts; R= 0 or 1 per >17K pts)

9. Behavioral Health Integration Phase 3

Behavioral Health Integration: IBHC Provider on board (G= 1 FTE per 1500-7500 enrollees and in synch with embedded BH Teams (eBH), A= 1 IBHC or in synch with eBH team per BDE, R = neither 1 IBHC or in synch with eBH

10. Pharmacist Integration Phase 3

Pharmacist Integration- providing medication therapy management; dispensing medications alone does not count: (G= 1 clinical pharmacist per 5K-8500 pts, A= 1 clinical pharmacist per PCMH practice, or part-time dispensing meds and clinical consultation, R= integrated clinical pharmacist not assigned

PCMH Total Score

Greater than or equal 7.5 = min score to operate effectively

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Task 4. Perform Gap Analysis (continued) 285 286 Funding for core support staff is provided in the fiscal year that the practice seeks NCQA 287 recognition. The practice conducts a staffing gap analysis using the MEDCOM approved 288 PCMH Support Staff Gap Assessment Template. The gap analysis is submitted through 289 the RMC to the Office of The Surgeon General (OTSG) for approval. MEDCOM 290 distributes funds based on the RMC validated and MEDCOM approved gap analysis. 291 Hiring actions will occur in the year of funding. 292 293 The MEDCOM PCMH Support Staff Gap Assessment Template is available at the PCMH 294 portal and through each RMC PCMH task force. 295 296 The required PCMs and core support staff are auto calculated based on the staffing ratio 297 in OPORD 11-20, annex D. The MTF enters “on-hand” staffing, including existing open 298 vice hiring actions. Chief nurse officer in charge (CNOIC)/noncommissioned officer in 299 charge (NCOIC) and staff assigned in a table of distribution and allowances (TDA) 300 position not working in the PCMH count as “on-hand.” 301 302 Gap analysis results determine funding and hiring requirements. Once the gap analysis is 303 validated by the RMC, it is the official record of requirement. Subsequent re-analysis is 304 not authorized unless a fundamental resourcing requirement has changed such as a 305 significant population shift which changes support staff requirements. 306 307 Task 5. Apply for 4th Level MEPRS Requirements as Specified by Army MEPRS 308 Program Office 309 310 All Army PCMH teams and practices will use Department of Defense (DOD) and Army 311 MEPRS Program Office (AMPO) guidance and business rules for 4th-level B*Z* MEPRS 312 code using approved and standardized file and table builds in multiple systems that will 313 align and support the B*Z* Army Medical Home MEPRS obtained from the AMPO. 314 315 Requests for B*Z* Army Medical Home MEPRS codes should be submitted to the MTF 316 MEPRS analyst who will forward to the AMPO office for approval. The AMPO office is the 317 only approval authority for MEPRS codes. No later than 30 days prior to receiving a 318 NCQA license, the practice completes the AMPO Army Medical Home Attachment. 319 Earlier submission is encouraged. Practices seeking NCQA recognition in FY13 must 320 submit Attachment 3 NLT 1 April 13. AMPO and MEDCOM PCMH task force will review 321 and approve submissions within 14 days of receipt. 322 323 Detailed instructions on the establishment of the new MEPRS can be found in the most 324 recent version of the AMPO guidance published each fiscal year and posted to the PCMH 325 Web site: https://www.us.army.mil/suite/page/661214 and OPORD 11-20 FRAGO 6. 326 327 Task 6. Close the Gaps 328 329 Closing the gaps occurs throughout the implementation process spanning all phases. 330

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Table 1, the PCMH Readiness Assessment Tool specifies which gaps need to be closed 331 to proceed to the next phase of implementation. 332 333 Personnel Gaps 334 The validated support staff gap analysis is the authorization document to hire. RMCs will 335 allocate funds and final hiring authorizations based on the gap analysis. Regions track 336 hiring actions in relation to the gap analysis. Once MTFs determine, RMC supports, and 337 MEDCOM/OTSG approves the manpower mix required to support the transition to the 338 PCMH delivery of primary care, MTFs must follow the guidance in the 7 May 2012 339 MCHR-C memo subject: Placement of Current Employees to Support Patient Centered 340 Medical Home (PCMH) to staff their PCMH clinics. Additionally, management must 341 ensure that personnel are aligned and placed against an authorized position in their 342 PCHM TDA in accordance with annex C (PCHM Structure) to OPORD 11-20. As this 343 process may take considerable time, this does not preclude the MTF from detailing the 344 existing staff and begin working under the new PCMH roles and responsibilities. Every 345 effort should be made to effect no-cost lateral reassignments, from and to the same 346 grade, to minimize the cost for the PCMH. 347 348 PCMH team members work at the “top of their license or scope of practice.” MEDCOM 349 has classified and published standard job descriptions for most positions in the PCMH. 350 Some classifications are at a higher grade than legacy positions. Use of new position 351 descriptions is required to ensure that the care team can operate at higher levels and 352 perform the new work required in the PCMH model. The MTF can submit UFRs to fund 353 upgrading existing staff to a higher grade. MTFs must engage with the local Civilian 354 Personnel Advisory Center and Union to ensure compliance with labor and hiring 355 practices as needed. Hiring and manning plans must be completed in advance of the 356 resourcing year. The comprehensive list of standardized position descriptions is available 357 through RMC and MEDCOM Human Resources and posted on the PCMH Web site. 358 359 Training Gaps 360 Core Content Training, TeamSTEPPS Training, MAPS 2.0/TriService Workflow (TSWF) 361 Training, and Integrated Clinical Database (ICDB)/CarePoint (“PCMH Huddle Tool”) are 362 critical training elements for the PCMH. Training on these can begin in the Prepare Phase 363 with practice ready and trained by the end of the Recognize Phase. Sustainment and 364 refresher training are ongoing activities to maintain the competence and effectiveness of 365 the practice. The PCMH must have a plan to effectively “on board” new employees with 366 critical training elements. 367 368 Facilities/Equipment Gaps 369 RMCs will conduct facilities assessments to meet the two exam room per provider 370 readiness criteria and optimize facility utilization to support PCMH implementation. 371 Funding for facility modification projects will come out of core sustainment, 372 recapitalization, and maintenance (SRM) funds. Any projects that exceed SRM funding 373 budgets or thresholds will be submitted through normal request channels specifically 374 identified in support of PCMH. RMCs will conduct similar assessments for medical and IT 375 equipment to support PCMH. Funding will be processed through normal Capital 376

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Equipment Expense Program (CEEP) channels specifically identified in support of 377 PCMH. 378 379 2-2 Phase II: Recognize 380 381 Army Medicine’s goal is for all direct care enrollees to be seen in an Army PCMH 382 recognized by NCQA as Level 2 or above no later than 1 October 2014. The RMC will 383 conduct a readiness assessment for all practices using the readiness assessment criteria 384 as one method to determine when a practice is ready to seek recognition. A score of 7.5 is 385 considered the minimum to operate effectively as a PCMH, but is not a limiting factor for 386 seeking recognition. The practice will begin familiarization with the NCQA standards 387 during the preparation phase and should be ready to begin the process immediately. 388 Phase 2 begins when the practice receives a license from NCQA. NCQA recognition will 389 take no longer than 180 days. 390 391 The Surgeon General/MEDCOM Commander and the Deputy Commanding General for 392 Operations are closely tracking the accelerated transformation of primary care into 393 PCMH practices. Implementation actions that will be tracked strategically by MEDCOM 394 are— 395 396

• 2 exam rooms per provider. 397 • MAPS 2.0 training. 398 • 4th Level MEPRS code activated. 399 • RMC SAV completed using Transformation Assessment Tool checklist 400

(successful performance on metrics is NOT required for transformation). 401 • NCQA level 2 or 3 recognition. 402

403 Task 1. NCQA Application 404 405 Once practices are confirmed for participation in the NCQA recognition process, 406 MEDCOM obtains a license specific for each practice. NCQA will contact the practice 407 directly via email to provide access to the NCQA website. Phase II begins officially on the 408 day the practice receives the license from NCQA and will have 180 days to complete the 409 survey and receive recognition results. The practice provider, nurse, and administrative 410 teams will work together to complete the survey for recognition. MEDCOM will coordinate 411 the NCQA process through the RMC. 412 413 Additional NCQA information is available at the PCMH Web site at PCMH Portal (on 414 AKO): https://www.us.army.mil/suite/page/661214. 415 416 Task 2. Training 417 418

• Core Content Training 419 The Army PCMH Core Content training has been developed by MEDCOM and will be 420 provided by the RMC Transformation Teams. Training modules are aggregated into two 421 multi-day blocks of training: Step 1 and Step 2. Steps 1 and 2 can be completed in 422

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separate training sessions or in one combined session. Training is not restricted to 423 primary care staff. All involved sections of the ACO attend training. Initial and sustainment 424 training resources include the Army PCMH Interactive Multi-Media Instruction Suite 425 produced through the AMEDD C&S and available on-line or by DVD. 426 427

• TeamSTEPPS Training 428 TeamSTEPPS training is essential to enhanced care team performance and patient 429 safety. TeamSTEPPS training requirements are defined in MEDCOM OPORD 11-38 at 430 the Army PCMH Web site: https://www.us.army.mil/suite/page/661214. 431 432

• MAPS 2.0/TriService Workflow (TSWF) Training 433 In accordance with OPORD 11-47 (MEDCOM AHLTA PROVIDER SATISFACTION - 434 MAPS) and subsequent FRAGOs, and following guidance provided in the MAPS 2.0 435 Executive Playbook with related training and implementation resources, MTF leaders 436 ensure readiness, deployment, and sustainment of the standardized MAPS 2.0 program 437 in every PCMH. TriService Workflow Alternate Input Method (TSWF AIM) templates for 438 AHLTA with partnered MAPS tools are the required documentation tools used in the 439 PCMH. MAPS 2.0 using TSWF is an essential component of patient-centered workflow. 440 Leaders must ensure all clinical team members in the PCMH are properly trained in the 441 standard workflow processes and tools included in the MAPS 2.0 program, and that all 442 necessary infrastructure, hardware, and software are available and functioning at peak 443 performance. Adherence to the MAPS 2.0 standard program is monitored and enforced 444 locally. 445 446

• ICDB/CarePoint (“PCMH Huddle Tool”) 447 Leaders will ensure that all staff in the PCMH responsible for huddle preparation have a 448 Carepoint account and receive adequate training on the use of the Huddle Tool. 449 Requests for Carepoint access are initiated through the MEDCOM Evidence Based 450 Practice office at (210) 221-6527. 451 452

• Army Medicine Secure Messaging Service 453 Army Medicine Secure Messaging Service (AMSMS) is a suite of capabilities intended to 454 reduce reliance on telephonic patient communications and to replace some face-to-face 455 visits related to chronic disease management. AMSMS is a secure system allowing for 456 communication between the patient and one or more members of their care team, as well 457 as between members of the care team and outside consultants involved in the patient’s 458 care. 459 460 AMSMS is intended to be the primary means of communicating with patients and team 461 members. Dedicated staff must be identified and trained using the MEDCOM AMSMS 462 standard train-the-trainer curriculum to maintain the system and provide sustainment 463 training. This is an MTF and RMC responsibility with support from the MEDCOM Project 464 Management Office and Capability Managers Office. Refer to AMSMS OPORD 12-57 465 any subsequent FRAGOS and the supporting guide and related support materials all 466 located at the PCMH Web site: https://www.us.army.mil/suite/page/661214. 467 468

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Task 3. Optimize Empanelment 469 470 Optimal provider panel size is the cornerstone of providing timely access and patient care 471 management. The combination of provider available time to see patients, panel acuity, 472 and patient utilization determine an optimal panel size for which access to comprehensive 473 care is assured. The practice and ACO collaborate to achieve the following objectives: 1) 474 optimum balance between PCM core team and PCM Home available time for care 475 (face-to-face and virtual) and the measured demand by their empanelled beneficiaries, 2) 476 panel parity including even distribution of high utilizers, high acuity, or patients with 477 multiple chronic conditions among PCM core teams and PCM homes, 3) active 478 monitoring, reporting, and management of access trends such as utilization rate, 479 satisfaction with access, available clinician time, and movement of significant patient 480 population over extended time periods such as deployments or base realignments. 481 482 For detailed guidance regarding determination of panel sizes see PCMH OPORD 11-20, 483 Annex I at PCMH Web site: (https://www.us.army.mil/suite/page/661214) and the PCMH 484 Operations Manual. 485 486 Task 4. Activate/Implement 4th Level MEPRS Utilization 487 488 Practices will transition to new MEPRS code and deactivate legacy codes before the end 489 of Phase II. It is imperative that practices aggressively act to accomplish this task to 490 provide effective performance measurement and accountability of financial and human 491 resources in the PCMH. The AMPO and MEDCOM PCMH program office will review 492 financial systems and Composite Health Care System (CHCS) files and table to validate 493 correct implementation and data quality after the new codes are operational. Practices in 494 phase II are required to report weekly status reports through the RMC to MEDCOM 495 AMPO until the new codes are operational. 496 497 Task 5. Transformation Assessment Visit 498 499 Staff assistance visits will be conducted by the RMC using the Transformation 500 Assessment Tool as the standard to assess successful implementation of core principles 501 and standards within the PCMH practice and ACO. Successful achievement of 502 performance benchmarks detailed in the tool is not required for Army PCMH recognition. 503 The PCMH Transformation Assessment Tool tracks the healthcare delivery process 504 starting with Patient Welcome and progressing through Empanelment, The Care Team, 505 Accessing Care, Service Standards and Workflow, Integrated Care, Patient Activation, 506 Care Coordination, and Process Improvement. 507 508 Task 6. Submit an NCQA Survey 509 510 The practice completes the NCQA survey online through the NCQA website. The RMC 511 will conduct a quality control review of the survey before submission. The goal is to submit 512 the survey in time to receive recognition within 180 days of receiving the license. NCQA 513 can take up to 30 days to complete a full review. Practices will use the 2011 NCQA 514

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Standards. Practices must achieve a score of 50% or higher on must-pass elements. 515 NCQA Standards are aligned with the six primary care core components— 516 517

1. Enhance access and continuity. 518 2. Identify and manage patient populations. 519 3. Plan and manage care. 520 4. Provide self-care and community support. 521 5. Track and coordinate care. 522 6. Measure and improve performance. 523

524 Task 7. Become a Validated Army Patient Centered Medical Home 525 526 A practice becomes an official Army PCMH when it meets three criteria: 527

• Practice readiness assessment of 7.5 or greater. 528 • NCQA recognition level 2 or higher. 529 • Successful validation by the RMC Transformation Team during an SAV utilizing 530

the Transformation Assessment Tool. 531 532 2.3 Phase III: Perform 533 534 In Phase III, the clinic has achieved Patient Centered Medical Home status. The practice 535 will have just begun the journey to operating as a PCMH. During Phase III the practice will 536 continue to close the resource gaps and implement advanced capabilities of the PCMH 537 such as advanced access and extended team member integration. The Army PCMH 538 Operations Manual is the official reference for the Army PCMH. 539 540 Successful PCMH practices achieve their full potential to improve the healthcare 541 experience by providing continuity and coordination of care, proactive population-based 542 health management, preventive and wellness services and support for patient 543 self-management. MTFs remain accountable for the performance of tactical level 544 measures for all tasks of OPORD 09-36 (Access to Care Campaign) and both FRAGO 1 545 & 2 to OPORD 09-36, unless otherwise superseded by OPORD 11-20. 546 547 Current (JAN 2013) strategic metrics are-- 548

• Enrollment from Enrollment Capacity Model. 549 • Emergency room utilization. 550 • Network leakage of primary care (where enrollees go for care). 551 • PCM by name continuity (volume and percentage). 552 • Patient satisfaction (APLSS question 20). 553 • Staff satisfaction (MEDCOM Speaks!). 554 • HEDIS® Composite Score. 555 • Medical Readiness Category (MRC) Category 4. 556

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CHAPTER THREE 559 PCMH ROLES AND RESPONSIBILITIES 560

561 3-1. Accountable Care Organization 562 563 Army Medicine is transforming to a Patient-Centered System For Health, dedicated to 564 providing a consistent patient experience. PCMH teams promote the delivery of 565 comprehensive, high quality health care in a fully coordinated and synchronized manner. 566 The PCMH team roles and responsibilities are outlined in figure 3 and table 2,below, and 567 include the PCM core team, PCMH practice, and ACO. 568 569 The ACO consists of the MTF leadership and all clinical and non-clinical support activities 570 responsible for health care and support to the same group of beneficiaries. The ACO 571 includes, but is not limited to: human resources, information management, resource 572 management, managed care, in addition to primary care, subspecialty, and surgical care 573 lines. Leaders of these staff activities, as well as their subordinates, must understand the 574 PCMH mission and appreciate the priority of effort required to support the 575 patient-provider partnership. 576 577

Figure 3. PCMH Collaboration Model 578

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3-2. PCMH Staff Model 580 581 The PCMH staffing model is defined in OPORD 11-20, Annex C. Commanders and 582 leaders at all levels must realign and reassign personnel from within the organization 583 (based on utilization data) prior to pursuing hiring actions. 584 585 3-3. Medical Neighborhood 586 587 The Medical Neighborhood consists of the network of other clinicians and services 588 providing health care to patients. The Medical Neighborhood is expected to deliver 589 coordinated care, effective communications, and shared decision-making. It is intended 590 to improve the patient experience, improve patient outcomes, improve patient safety, and 591 reduce healthcare costs. The Medical Neighborhood includes inpatient care, post-acute 592 rehabilitation, emergency care, specialty and subspecialty care, ancillary services 593 (physical therapy, occupational therapy, podiatry, and speech therapy), diagnostic 594 services (laboratory and radiology), and patient education and health promotion 595 programs (wellness/preventive medicine). 596 597 Table 2. Roles and Responsibilities (PCMH, Medical Neighborhood, ACO) 598

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PCMH LEVEL ROLES KEY RESPONSIBILITIES RATIO

PCMH CORE TEAM

• Medical Director/Clinic OIC

The senior clinical expert and primary clinical decision maker for the PCMH Home.

1 FTE per PCMH Home

• Primary Care Manager (PCM) MD/DO/NP/PA

Provides coordinated, comprehensive primary care to empanelled Patients.

Per enrollment guidelines in MEDCOM OPORD 11-20, Annex I

• Team Registered Nurse (RN)

Leads the continuity of care delivery and care plan implementation, establishes priorities for patient care, evaluates patient progress and provides patient education.

Part of 3.1 core team staff. Refer MEDCOM OPORD, Annex D.

• Licensed Practical Nurse / Licensed Vocational Nurse (LPN/LVN)

Provides direct nursing care within scope of practice, assists with the implementation of the care plan.

Part of 3.1 core team staff. Refer MEDCOM OPORD, Annex D.

• Medic Provides direct nursing care within scope of competencies, assists with the implementation of the care plan.

Part of 3.1 core team staff. Refer MEDCOM OPORD, Annex D.

• Certified Nurse Assistant (CNA); Medical Technicians; Medical Assistants

Provides direct nursing care within scope of competencies, enhances PCM functioning by supporting daily clinical procedures.

Part of 3.1 core team staff. Refer MEDCOM OPORD, Annex D.

• Medical Clerk / Administrative Assistant (MA)

Provides direct administrative patient support services, acts as the front line customer service advocate, and serves as the communication link between the

1 FTE per 3 FTE PCM Refer to annex OPORD 11-20, AnnexD-1

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PCMH LEVEL ROLES KEY RESPONSIBILITIES RATIO

patient and the PCM care team.

PCMH PRACTICE

• Practice Manager Provides management oversight of clinic operations. 1 FTE per >10,000 enrollees

• Clinical Nurse OIC (CNOIC)

Oversees the scope of practice and provision of nursing services provided.

Part of 3.1 core team staff. 1 FTE per Practice

• Clinical NCOIC Oversees and consults on the scope of practice and provision of care provided by the technicians and enlisted staffs.

Part of 3.1 core team staff, if not at department level. 1 FTE per Practice

• Nurse Case Manager (NCM)

Synchronizes healthcare management for patients with chronic, catastrophic, or complex medical conditions, or identified as high utilization or high risk.

Part of 3.1 core team staff. 1 FTE per >6500

• Population Health Nurse

(PHN)

Coordinates and implements health promotion practices and measures.

Part of 3.1 core team staff. 1 FTE per 10 FTE PCMs

• Behavioral Health (BH) Provider

Provides coordinated, short-term Behavioral Health care, assists PCMs in recognizing and treating BH disorders and psychosocial problems.

1 FTE PER > 7500 enrollees

• Pharmacist Provides coordinated medication management, identifies medication related problems, develops care plans with therapy goals, and serves as medication educator for both Patients and providers.

1 FTE per > 6500 enrollees (amended in Operations Manual)

• Dietitian Provides coordinated nutrition education and support to targeted populations, groups and individuals.

1 FTE > 7500 enrollees

600

19

MTF

ACO/Clinical Neighborhood

• Information Management Director (IMD)

• Chief Medical Information Officer (CMIO)

Supports all IM/IT infrastructure requirements, manages MAPS 2.0, AMSMS, and ICDB/CHAS training and implementation.

• Human Resources (HR)

Manages hiring actions for validated medical home positions, assists with gap analyses for staffing, performs realignment and reassignment actions.

• Operations/Training Tracks training in DTMS/APEQS, manages taskers, tracks and coordinates SAV/OIP. Manages “Mobilization Plan.”

• Logistics Supports and manages all supply and equipment needs. • Facilities Management Performs space requirement assessments and allocation to optimally

support integrated practice activities. • Public Affairs Office (PAO)

Leads strategic communications planning and activities related to marketing focused on both Patients and staff.

• Managed Care / CLINOPS / PAD

Manages Patient enrollment and empanelment to support optimal patient care.

• Central Appointments Supports the medical home by appropriately appointing Patients to the proper PCM/team.

• Exceptional Family Member Program (EFMP)

Identifies and manages Family Members with special care needs.

• Radiology Provides comprehensive, timely radiology services. • Laboratory Provides comprehensive, timely laboratory services. • Emergency Department Ensures timely feedback by actively communicating with PCMH team

regarding patient Emergency Department visits. • Quality Management (QM)

Supports credentials and privileging of all providers and care team, leads TeamSTEPPS™ training.

• Referrals Management Manages and coordinates network referrals and consultations, ensures timely feedback to referring provider.

• Resource Management (RM)

Coordinates with MEDCOM for assignment and activation of MEPRS codes, assists with manpower and PCMH data analyses.

• Graduate Medical Education (GME)

• Staff Education & Training

Supports all mandatory initial and sustainment training requirements for the PCMH staff.

601

602

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Appendix A 603 References 604 605 All references will be maintained on the PCMH Web site at 606 https://www.us.army.mil/suite/page/661214 607 608 For additional Information on the role of the Guiding Coalition in accelerating successful 609 change, see: “Accelerate” John P. Kotter, Harvard Business Review, November 2012. 610 611

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GLOSSARY 612 613 Section I 614 Abbreviations 615 616 ACO 617 Accountable Care Organization 618 619 AMEDD C&S 620 Army Medical Department Center and School 621 622 AMH 623 Army Medical Home 624 625 AMPO 626 Army MEPRS Program Office 627 628 AMSMS 629 Army Medicine Secure Messaging Service 630 631 ATRRS 632 Army Training Requirements and Resources System 633 634 CBMH 635 Community Based Medical Home 636 637 CEEP 638 Capital Equipment Expense Program 639 640 CHAS 641 CarePoint Healthcare Application Suite 642 643 CHCS 644 Composite Health Care System 645 646 CHUP 647 Chronic Disease, High Utilizer, Polypharmacy 648 649 CNA 650 certified nurse assistant 651 652 CNOIC 653 chief nurse officer in charge 654 655 CPG 656 clinical practice guideline 657

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658 DMHRSi 659 Defense Medical Human Resources Systems Internet 660 661 DOD 662 Department of Defense 663 664 EHR 665 electronic health record 666 667 FTE 668 full-time equivalent 669 670 HEDIS® 671 Health Effectiveness Information Data Set 672 673 IBHC 674 Internal behavioral health consultant 675 676 ICDB 677 Integrated Clinical Database 678 679 LPN 680 licensed practical nurse 681 682 LVN 683 licensed vocational nurse 684 685 MAPS 686 MEDCOM AHLTA Provider Satisfaction 687 688 MEDCOM 689 (U.S. Army) Medical Command 690 691 MEPRS 692 Medical Expense Performance Reporting System 693 694 MHS 695 Military Health System 696 697 MM 698 medical management 699 700 MTF 701 military treatment facility 702 703

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NCM 704 nurse case manager 705 706 NCOIC 707 noncommissioned officer in charge 708 709 NCQA 710 National Committee for Quality Assurance 711 712 OHI 713 other health insurance 714 715 OIC 716 officer in charge 717 718 OTSG 719 Office of The Surgeon General 720 721 PCM 722 primary care manager 723 724 PCMH 725 Patient Centered Medical Home 726 727 PCTS 728 Patient Caring Touch System 729 730 PHN 731 population health nurse 732 733 RD 734 registered dietitians 735 736 RMC 737 regional medical command 738 739 RN 740 registered nurse 741 742 SCMH 743 Soldier Centered Medical Home 744 745 SRM 746 sustainment, recapitalization, and maintenance 747 748 TDA 749

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tables of distribution and allowances 750 751 TJC 752 The Joint Commission 753 754 TOL 755 TRICARE Online 756 757 TSC 758 TRICARE Service Center 759 760 TSWF 761 TriService Workflow 762 763 TSWF-AIM 764 TriService Workflow Alternate Input Method 765 766 UFR 767 unfinanced requirement 768 769 Section II 770 Terms 771 772 Access Call Center 773 A single telephonic point of entry to respond to appointment requests via phone for all 774 primary care (MEDCOM Policy 10-063). 775 776 Accountable Care Organization 777 An organization responsible for healthcare and support to the same group of 778 beneficiaries. This includes but is not limited to the MTF leadership, all clinical and 779 non-clinical support activities such as Human Resources, Information Management, 780 Resource Management, Managed Care, in addition to primary care, subspecialty, and 781 surgical care lines. The organization's reimbursement and resourcing is tied to 782 achievement of healthcare quality goals and outcomes that result in cost savings. 783 784 Army Medicine Secure Messaging Service (AMSMS) 785 Secure messaging is a commercial, web-based, secure platform that provides a robust 786 set of services designed to allow patients and their healthcare team to communicate 787 privately, at times and locations that are convenient. This secure platform works very 788 much like an on-line secure banking web site. 789 790 B.A.S.I.C. Communication Tool 791 An acronym to ensure staff meets our patients’ needs in a proactive manner. 792

Break Barriers: If there is an issue or situation preventing the delivery of our best 793 services, it is our responsibility to break barriers to solve the problem. 794

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Anticipate and Accommodate: Individual experience and intuition tell us when 795 there is a need to be met. Act immediately to meet the need. 796 Seek Solutions: The world is full of problems. We take pride in our individual and 797 organizational ability to find solutions. 798 Initiate and Interact: When someone approached us, we look at them and start 799 the conversation by saying "hello" or "how can I help you?" 800 Communicate: Be clear. Always include intent in your comment or questions. 801 Ask a question to make sure the other person understood what you intended to 802 communicate (PCMH Training module). 803

804 Care Coordination 805 An approach to care management using proactive methods to optimize health outcomes 806 and reduce risks of future complications over a short-term (two to six weeks) single 807 episode of care. Prospective and concurrent reviews are used to identify current and 808 future beneficiary needs (http://www.tricare.mil/mybenefit/Glossary.do?F=C). 809 810 Care Plan 811 A document that identifies nursing orders for a patient and serves as a guide to nursing 812 care. It can be written for an individual patient, retrieved from a template and 813 individualized, or preprinted for a specific disease, condition, or nursing diagnosis and 814 individualized to the specific patient. Standardized care plans are available for a number 815 of patient conditions. Successful care plans are patient specific and should address the 816 total status of the patient to ensure optimal outcomes for patients during the course of 817 their care. 818 819 CarePoint 820 An application Portal is the DoD healthcare application framework for business 821 intelligence, healthcare content management, user collaboration and personalization. 822 CarePoint is the common development platform providing quick implementation of 823 healthcare applications with a consistent and familiar user experience. 824 825 Case Management 826 A collaborative process of assessment, planning, facilitation, care coordination, 827 evaluation, and advocacy for options and services to meet an individual’s and family’s 828 comprehensive health needs through communication and available resources to 829 promote quality cost effective outcomes (Case Management Society of America, 830 www.cmsa.org). 831 832 Daily Huddle 833 “A team meeting to ensure efficient patient visits by discussing patients on the day’s 834 schedule. A communication process may include email exchanges or messages in the 835 medical record about the patient. NCQA reviews the practice’s communication process 836 and an example of a meeting summary, agenda or memo to staff.” (www.ncqa.org: The 837 ACO Structure, 2005) 838 839 Empanelment 840

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The process by which primary care managers are identified and individual TRICARE 841 Prime enrollees are assigned to them. Only TRICARE Prime Enrollees will be 842 empanelled (Health Affairs Policy Memorandum 97-041). 843 844 Enrollment 845 The process by which participation status in the TRICARE MHS Managed Care Program 846 is established (http://www.tricare.mil). 847 848 Handshake Medicine 849 Policies and procedures to guarantee a consistent patient experience and effective 850 transitions for both patients and staff from one location to another across Army Medicine. 851 852 HEDIS®-(Healthcare Effectiveness Data and Information Set) 853 The Healthcare Effectiveness Data and Information Set (HEDIS®) is a tool used by more 854 than 90 percent of America's health plans to measure performance on important 855 dimensions of care and service. Altogether, HEDIS® consists of 75 measures across 8 856 domains of care. Because so many plans collect HEDIS® data, and because the 857 measures are so specifically defined, HEDIS® makes it possible to compare the 858 performance of health plans on an "apples-to-apples" basis (www.ncqa.org). 859 860 Integrated Clinical Database (ICDB) 861 The ICDB is an effective “user-friendly” system that presents clinical data in a tailored, 862 manageable structure. With a uniform architecture and integrated views for the provider 863 team, it supports patient care, data analysis, and research. While leveraging legacy 864 systems such as CHCS, it enables a transition platform for emerging technologies. 865 (http://www.himss.org/content/files/ambulatorydocs/ICDB.pdf) 866 867 Lifespace 868 Also see White Space. The Lifespace is when we make decisions on sleep, activity, and 869 nutrition. We estimate that most patients visit a doctor 1 to 5 times a year, and each visit 870 is about 20 minutes each. Those 100 minutes is the most we can influence patient 871 health. The other 525,500 minutes in our lives is when we’re at work, or at home with our 872 families. It’s in this Lifespace where the choices we make impact our lives and our 873 health. In this Lifespace, we want to focus on the Triad of factors that our patients can 874 become invested and help to manage their health—Activity, Sleep and Nutrition. 875 876 Nurse Advice Line 877 TRICARE defines Nurse Advice Line as providing around-the-clock access to medical 878 information and advice. The Nurse Advice Line provides RNs who can answer 879 questions, provide self-care advice, and help you decide if you need to seek immediate 880 care; an audio health library with easy-to-understand information on hundreds of topics. 881 Help with managing chronic conditions, such as diabetes or asthma. In some locations, 882 the nurse may be able to directly schedule appointments at your military treatment facility 883 if needed (www.tricare.mil). 884 885 Operating Company Model 886

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The OCM is foundational approach to organization that leverages centralized control, 887 decentralized execution to an enterprise-wide organizational standard. An OCM is 888 designed around integrated, standard processes across the organization. Performance 889 metrics and decision-making are clearly defined for these processes, driving 890 accountability. High focus and priority is given to process quality, repeatability, and 891 standards to drive a better, more consistent patient experience while also containing 892 costs. The OCM emphasizes clarity, consistency and accountability across five pillars: 893

• Process structure: How we get things done to a high quality standard 894 • Organizational structure: How we deploy our people in support of our mission 895 • Governance and decision-making: Who “makes the call” when we have competing 896

priorities 897 • Performance metrics and accountability: How we understand and communicate our 898

performance 899 • Culture: How we work together to support these goals and make them part of our 900

“DNA” 901 902 Polypharmacy 903 A patient treated for multiple conditions with a variety of medications prescribed by 904 several healthcare providers. When a patient receives four or more medications that 905 include one or more psychotropic agents and/or central nervous system depressants, 906 within a 30 day-period they meet the definition for polypharmacy. 907 908 Primary Care Provider (aka Primary Care Manager, PCM) 909 A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse 910 practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, 911 who provides, coordinates or helps a patient access a range of healthcare services. 912 913 TRICARE Online 914 Provides secure access to online features such as appointments, prescriptions, and 915 personal health data for DoD beneficiaries receiving care through a military treatment 916 facility. 917 918 White Space 919 Also see Lifespace. The time between doctors’ visits and that this is where the majority of 920 decisions that affect an individual’s health are made. She spoke of the need to reach 921 patients on an individual level and to empower them in maintaining and enhancing their 922 own health and well-being (The Surgeon General of the United States Army; 923 http://www.dvidshub.net/news/83066/military-health-period-transformation-says-woodso924 n-rooney-horoho#ixzz2Fdk3qBux). 925 926 927

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FEEDBACK AND IMPROVEMENTS 928 929 The PCMH Transformation Team welcomes feedback and improvements to this 930 implementation manual. Recommendations can be communicated via the link at 931 https://www.us.army.mil/suite/page/661214 , the Army Knowledge On Line webpage for 932 PCMH. All recommendations will receive consideration and response. A series of active 933 tasks is being worked as Task Action Plans (TAPs) by the PCMH TF. As these action 934 items are completed, additional standards and capabilities will be included in quarterly 935 updates to the PCMH Implementation and Operations Manual. All updates will be sent 936 electronically through wide distribution and will be posted on PCMH AKO webpage and 937 MEDCOM PCMH SharePoint sites. 938 939 940