ARMY PCMH SCMH ManualLeaders Guide to Army Soldier Centered Medical Home Transformation

13FEB14

2

EXECUTIVE SUMMARY

The Army Soldier Centered Medical Home (SCMH) is the Soldier’s version of thePatient Centered Medical Home (PCMH). The SCMH mission is to improve andenhance individual and unit medical readiness, utilizing the PCMH multi-disciplinaryhealthcare team approach, consisting of primary care, behavior health, clinicalpharmacy, physical therapy, nutrition care, and nurse case management, operating in aproven model of integrated, comprehensive, proactive care. The SCMH providesenhanced services located in close proximity to the Soldier’s primary work area, ideallywithin walking distance, thereby improving access and minimizing lost duty time.

The SCMH’s coordinated and integrated focus will ensure timely, accurate diagnoses,optimized return-to-duty rates, and decreased Soldier recovery times. Ultimately, all ofthese elements contribute positively to increased readiness. The SCMH targets allactive duty Soldiers.

This Guide augments and compliments, but does not replace, the Army PCMHImplementation and Operations Manuals.

Figure 1: SCMH functions through coordination with internal and synchronized activities.Internal activities are located within and are integral to the functionality of the SCMH. Althoughsynchronized activities operate separately from the SCMH, they follow and adhere to keypolicies and procedures to ensure seamless care coordination and care transitions with theSCMH. The SCMH and synchronized activities are part of the MTF operating as an AccountableCare Organization (ACO) connecting to patients in their Lifespace.

3

TABLE OF CONTENTSPAGE

EXECUTIVE SUMMARY

CHAPTER ONE- BACKGROUND

1-1. Definition……………………………………………………………. 4

1-2. Intent………………………………………………………………… 4

1-3. Context……………………………………………………………… 4

1-4. Leadership design…………………………………………………. 6

1-5. Size………………………………………………………………….. 6

CHAPTER TWO – IMPLEMENTATION

2-1. Prepare, recognize, and perform…………………………………. 8

2-2. Staffing……………………………………………………………….13

2-3. Training………………………………………………………………15

2-4. Facilities and information technology……………………………. 16

2-5. Installation Health Services Plan (IHSP) andSenior Medical Council……………………………………………..17

CHAPTER THREE – OPERATIONS

3-1. Soldier patient workflow…………………………………………… 18

3-2. Roles and responsibilities………………………………………….18

3-3. Huddle………………………………………………………………. 19

3-4. Non-face-to-face care………………………………………………19

3-5. Care coordination, transitions in care, andcase management………………………………………………….19

3-6. Performance standards…………………………………………….19

4

CHAPTER ONEBACKGROUND

1-1. Definition

The Soldier Centered Medical Home (SCMH) is the Soldier’s version of ArmyMedicine’s Patient Centered Medical Home (PCMH) in which 90 percent of all requiredcare is provided to maintain Soldier medical readiness. OPORD 12-50 directedimplementation of SCMH across the enterprise no later than (NLT) fiscal year (FY)15 forthe U.S. Army Forces Command (FORSCOM), U.S. Army Europe (USAEUR), and U. S.Army Pacific (USARPAC). U.S. Army Training and Doctrine Command (TRADOC) andU.S. Army Special Operations Command (USASOC) units will be incorporated NLTFY15 into the Army-wide plan.

1-2. Intent

The SCMH concept of operations is entirely consistent with PCMH principles. SCMH isdesigned around the brigade or brigade equivalent troop population (~4000 Soldiers) asthe scalable unit for which support staff, facility, information technology, and otherequipment requirements are planned. Brigade combat teams (BCTs), combat aviationbrigades, and regiments are first priority unit types, but SCMH is intended for allbrigade-sized equivalents. The primary distinction between the SCMH and the PCMH isthe integrated staffing model, in which the organic unit medical staff provides care withintheir scope of practice for their assigned Soldiers. Typically, units provide medics,physician assistants, and physicians (brigade and/or battalion surgeons) to support theprimary care requirements for their assigned Soldiers. Many units have assignedbehavioral health officers, physical therapists (PTs), nurses, and other medicalprofessionals available who also provide health care within their scope of practice. Insome examples, embedded behavioral health teams (EBHTs) are already aligned withthe supported unit. In all cases, the intent is to synchronize SCMH implementation withembedded behavioral health (EBH) implementation and operations. Ideally these twoservices would be co-located in the same building. The installation medical treatmentfacility (MTF) augments organic unit medical staff with primary care managers (PCMs)and specialists such as clinical pharmacists, nurse case managers, dietitians, PTs,behavioral health (BH) providers, and support staff to complete the SCMH staffingmodel. Synchronization with current BH and Integrated Disability Evaluation Systeminitiatives is critical to success. A map of all current and future SCMH locations isincluded in appendix A.

1-3. Context

Soldier medical readiness requirements have evolved over 12+ years of war and ArmyMedicine is responding to these identified needs by creating a more comprehensive andcapable system to provide the highest level of care to our Soldiers. SCMH provides theresources and functionality to address 90 percent of Soldier care needs (see fig 2) andmaximize health to optimize performance.

5

Figure 2. Soldier medical needs

SCMH is a line of effort (that is, LOE) within the PCMH and is in support of the ArmySurgeon General’s Army Medicine 2020 Campaign (see fig 3).

COL Mark Reeves / PCMH TF (210) 221-7055 / mark.m.reeves.mil@mail.mil FOUO 17 May 2013Slide 2

Patient Centered Medical HomeLines of Effort

CampaignObjective –• Accountable, Reliable,and EffectiveHealth Services

Campaign Objective –• Consistent Patient

Experience

Campaign Objective –• Maintain Health• Restore Health• Improve Health

Army Medicinerecognized as a

national andinternationalhealth leader

System For Health

Campaign Objective –• Shape the Narrative

Campaign Objective –• Collaborate, Develop,

and StrengthenPartnerships

Campaign Objective –• Combat Unhealthy

Behaviors andLifestyles

Campaign Objective –• Enable Active

Communities andHealthy Environments

Campaign Objective –• Increase Performance

and Resilience

Change inbehavior to

adopt healthylifestyle

PCMHMission:

Build thepremierpatient-

centered,team-based,

comprehensiveSystem ForHealth thatimproves

readiness andpromotes

health

ARMY PCMH: The Foundation of Health and Readiness

EndState:A high-

quality, highlyreliable,patient-

centeredconsistentexperience

for ourpatients and

providersacross theenterprise

thatemphasizes

health

Create Capacity - Capabilities / core competencies that optimize health care and health

Patient / Soldier Centered Medical Home Behavioral Health System of Care

Transform Reimbursement System IM/IT Health Mobility Ready andresilient Force,Families, andCommunities

Integrated Disability Evaluation System

Performance Measurements

Enhance Diplomacy – Change the conversation on healthcare delivery and health

Medical DiplomacyPartnering, Communicating, and

Leading Health

Improve Stamina – Increase organizational depth and individual resiliency

Performance Triad (Activity, Nutrition, Sleep) Leader and Organizational Development Health Infrastructure

Figure 3. Patient Centered Medical Home lines of effort

As the Army restructures, SCMH will remain agile to adapt to changing locations andneeds as the Department of Defense (DOD) adjusts to financial and political pressures.SCMHs will continue to deliver highly reliable care and maximize Soldier readiness.

25%

15%

15%12%

9%

8%

6%

5%screening/wellness

"administrative encounters"

musculoskeletal pain/sxs

BH encounters

acute minor infections

chronic medical conditions

nursing led

other

pregnancy related care

eye care

nutrition care

derm

substance abuse

6

1-4. Leadership design

The leadership of the SCMH combines both modified tables of organization andequipment (MTOE) and MTF personnel to provide one synchronized effort for Soldierhealth and readiness. Figure 4 demonstrates the combined leadership structure of theSCMH. The MTF commander (director of health services) defines and ensures themedical standards for quality, safe health care are consistently met in addition toconfirming licensed independent professionals have completed all required training,certification, and current technical competence. The details of the medical support planare documented within the Installation Specific Health Service Plan (ISHSP) which isdirected by DA EXORD 15-10. The ISHSP will be signed by the regional medicalcommander (or designee) and the installation senior mission commander.

Figure 4. Combined SCMH leadership structure

1-5. Size

In the SCMH, the brigade PCMH “home” supports an individual brigade or brigade sizedequivalent (4,000 Soldiers). This design, including the associated support staff andextended team members, is equivalent in most respects to the PCMH home as bothprovide care for ~4000 enrollees. An SCMH practice will be no smaller thanBDE/brigade equivalent but no larger than a division (20K enrolled); just like a PCMHpractice. For Medical Homes supporting USASOC and TRADOC units, the size of theMedical Home will be determined by the unique requirements of the Soldiers beingsupported. Figure 5 compares the standard SCMH practice to PCMH practice.

Command relationship --- Functional/Professional relationship

7

Figure 5. Comparison of SCMH and PCMH practices

8

CHAPTER TWOIMPLEMENTATION

2-1. Prepare, recognize, and perform. The implementation roadmap (fig 6) defines thephases and critical tasks required to implement and operate an Army SCMH practice.Tasks can run sequentially and concurrently within each phase. Tasks such asreadiness assessment, gap analysis, and training are ongoing activities that aredynamic in nature and require constant review and adjustment over time.Implementation ends at the completion of phase II. A practice will receive Medical Homestatus (meets initial operating capability) when it satisfies these three criteria—

Practice readiness assessment score of 13.0 or higher National Committee for Quality Assurance (NCQA) recognition level 2 or higher Successful validation during a regional medical command (RMC) staff assistance

visit (SAV)

The MTF and RMC will report implementation progress and performance on a regularbasis as specified in OPORDs 11-20 and 12-50 and associated FRAGOs.

Figure 6. Implementation roadmap

9

a. Phase I: Prepare

Preparation involves all pre-implementation tasks and activities required to ready theSCMH practice(s) to receive NCQA recognition and operate as an Army SCMH. Thepreparation phase occurs prior to initiating the NCQA recognition process and shouldtake no longer than 180 days. The conversion to a standardized Medical ExpensePerformance Reporting System (MEPRS) code begins in this phase and is critical toperformance measurement and accountability of financial and human resources in theSCMH.

Task 1. Create a guiding coalition and formalize ISHSP

The guiding coalition is the multidisciplinary team constituted and empowered toimplement the Army SCMH model and formalize the ISHSP. This group will include lineand MTF leadership as well as medical leaders from both the unit and the MTF. AnISHSP template is available on the PCMH SharePoint Site:https://mitc.amedd.army.mil/sites/Communities/APCMHRC/Pages/default.aspx

Task 2. Communicate the vision

Communication is an enduring leadership responsibility and must be accomplishedthroughout the implementation and sustainment of the SCMH. Line and medicalcommanders and leaders will use every opportunity to relay the vision and purpose ofArmy SCMH transformation.

Task 3. Conduct baseline readiness assessment using the SCMH readinessassessment criteria

The readiness assessment criteria define the baseline from which a gap analysis isdeveloped. These standard criteria are reportable to MEDCOM and are scored asfollows:

Red = 0 Amber = 0.5 Green = 1.0

The sum of all factors defines the overall level of readiness. A total of 13 points is theminimum level to operate as an SCMH. Of note, PCMH practices containing SCMHs willbe held to the 13 point minimum. Table 1 lists the 17 criteria.

10

PCMH ReadinessAssessment

Phase Scoring Criteria Score

1. OptimizeEmpanelment

1

PCMs empanelled according to OPORD 11-20, FRAGO8, Annex I, Change 1 (G-= +/- 5% max capacity; A= +/-10% max capacity; R= more or less than 10% capacity);available clinical FTE must be validated by MTFcommander or designated surrogate

2. PCM ExamRooms/FTE(2 min)

1PCM exam rooms. (G > 2.0; A=1.8 - 2.0; R<1.8 examroom per provider FTE)

3. PCM Support Staffper PCM FTE(3.1 personnel)

2PCM core support team = number of support staff perPCM FTE; (G > 2.8; A=2.6 - 2.8; R<2.6 support staff)

4. RN Case ManagerSupport

2

Nurse case manager. (G-= +/- 5% staff ratio (1 per 6200enrollees); A= +/- 10% staff ratio; R= more or less than10% staff ratio); includes NCM from MedicalManagement Center; does not include BH-case manager

5. Practice ManagerSupport

2Practice manager. Specified staffing ratio is 1 practicemanager per 10K enrollees. (G=1 per 8-12K enrollees;A=1 per 12-17K enrollees; R= 0 or 1 per >17K enrollees)

6. Behavioral HealthIntegration

2

Behavioral health integration: IBHC provider on board(G=1 FTE per 1500-7500 enrollees and in synch withembedded BH teams (eBHs); A=1 IBHC or in synch witheBH team per brigade (BDE); R = neither 1 IBHC nor insynch with eBH)

7. 4th Level MEPRS 2

4th Level MEPRS. (G=MEPRS Code active andvalidated by MEDCOM; A=MEPRS request (Attachment3 IAW OPORD 11-20, FRAGO 7, Annex M) approved byMEDCOM, but not active or validated by MEDCOM; R=MEPRS request not approved by MEDCOM)

8. PCMH coretraining (17 modulesplus TeamSTEPPS™and PCTSorientation)

2

Training must be completed within 90 days of joiningPCMH staff and documented in Digital TrainingManagement System (DTMS) annually; (G> 90% of onhand staff current; A= 70-90% current; R<70% current)

9. Secure Messaging,TSWF, MAPS 2.0WorkflowOptimization,Training, &Infrastructure

2

AMSMS and MAPS 2.0 trained (IAW AMSMS OPORD12-57 and MAPS 2.0 OPORD11-47) and documented inDTMS (G >90% staff designated to use AMSMS andMAPS 2.0 Phase III complete; A=70-90% and MAPS 2.0Phase II complete; R<70% and/or MAPS 2.0 Phase II notcomplete)

10. PharmacistIntegration

3

Integrated clinical pharmacist must be directly involved inmedication management, aligned with the empanelledpatients and their care team, and integrated within team-based workflow. Specified staffing ratio is 1 pharmacistper 6500 enrollees. (G = 1 pharmacist to 5800-7200enrolled; A = 1 per <5800 or >7200 or 1 per 5800-7200but supporting remotely; R = no pharmacist aligned withPCMH/SCMH, or pharmacist only dispensing medication)

PCMH Total ScoreGreater than or equal 7.5 = min score to

operate effectively

11

CMH ReadinessAssessment

Phase Scoring Criteria Score

11. InstallationSpecific HealthService Plan(ISHSP) IAW DAEXORD 015-10

1G= ISHSP signed by senior commander and RMC CG;A= ISHSP in staffing, but unsigned; R= no ISHSP instaffing

12. Lab on site 1

G= Full lab on site or specimens obtained on site withsubmission for processing in <24 hours; A= Lab or drawcapability within walking distance of the SCMH; R= Labor draw capabilities not within walking capabilities of theSCMH

13. Pharmacy onsite

1

G= Full pharmacy on site at SCMH; A= Partial pharmacyon site or within walking distance of the SCMH;R=Satellite pharmacy not within walking distance of theSCMH

14. Radiology onsite

1

G= Radiology suite on site with full plain film capabilitiesand ASAP radiologist interpretation; A= Radiologycapability within walking distance of the SCMH andASAP radiologist interpretation; R= Radiology capabilitiesnot within walking capabilities of the SCMH or radiologistinterpretation not available within 4 hours of x raycompletion

15. PT area on site 1G= Functional PT area on site; A= Functional PT area atsatellite location within walking distance of SCMH; R= PTarea at MTF only

16. Physicaltherapist integration

3

Integrated physical therapist must be on site; aligned withassigned Soldiers, their unit providers, and the rest of thecare team; and integrated within the team-basedworkflow. Specified staffing ratio is 2 per BDE or BDEequivalent (4000 Soldiers). (G= 2.0 FTE per BDE orBDE equivalent; A= < 2.0 FTE or 2.0 FTE aligned withBDE but supporting remotely within walking distance ofSCMH; R= No physical therapist on site or within walkingdistance)

17. Dietitianintegration

3

Integrated dietitian must be aligned with empanelledpatients and their care team and integrated within team-based workflow. Specified staffing ratio is 1 dietitian per7500 enrollees. (G = 1 per 6700-8300; A = 1 per <6700or >8300 OR 1 per 6700-8300, but supporting remotely;R = no dietitian aligned with SCMH)

SCMH Total ScoreGreater than or equal 13.0 = min score to

operate effectively

Green (G) = 1, Amber (A) = 0.5, Red (R) = 0 points

Table 1. SCMH readiness assessment tool

Task 4. Perform gap analysis

To determine the personnel needs of the SCMH, Annex B, MEDCOM OPORD 12-50with associated spreadsheet defines the methods for conducting the baseline gap

12

analysis. The gap analysis results determine funding and hiring requirements. Once thegap analysis is validated by the RMC, it is the official record of requirement.

Starting in FY14, all PCMHs will be funded utilizing the Integrated Resource IncentiveSystem. This is a change from the previous methodology which used the gap analysescompleted between RMCs and the PCMH service line to meet NCQA standards.

Funds distribution will be based on personnel required to meet the enrollmentprojections set forth in the activity’s FY14 Performance Plan. The identified gap shouldsynchronize with additional personnel required to meet those enrollment projections.

Task 5. Apply for 4th level MEPRS requirements as specified by the Army MEPRSProgram Office

All Army SCMHs and practices will use DOD and Army MEPRS Program Office(AMPO) guidance and business rules for 4th-level BHZ* MEPRS code using approvedand standardized file and table builds in multiple systems that will align and support theBHZ* Army SCMH MEPRS code obtained from the AMPO.

Requests for BHZ* Army Medical Home MEPRS codes should be submitted to the MTFMEPRS analyst who will forward the request to the AMPO office for approval. TheAMPO office is the only approval authority for MEPRS codes. No later than 30 daysprior to receiving an NCQA license, the practice will complete the AMPO Army MedicalHome attachment (earlier submission is encouraged). The AMPO and MEDCOM PCMHtask force will review and approve submissions within 14 days of receipt.

Task 6. Close the gaps

Closing the gaps occurs throughout the implementation process spanning all phases.Table 1 (SCMH readiness assessment tool) specifies which gaps need to be closed toproceed to the next phase of implementation.

Personnel gapsThe validated support staff gap analysis is the authorization document to hire. RMCswill allocate funds and final hiring authorizations based on the gap analysis. RMCs trackhiring actions in relation to the gap analysis.

Facilities/equipment gapsRMCs will conduct facilities assessments to meet the two-exam-room-per-providerrequirement and lab, radiology, pharmacy, and physical therapy areas as detailed ingap analysis criteria and the readiness assessment tool. Funding for facility modificationprojects will come out of core sustainment, recapitalization, and maintenance (SRM)funds. Any projects that exceed SRM funding budgets or thresholds will be submittedthrough normal request channels specifically identified in support of the SCMH. RMCswill conduct similar assessments for medical and information technology (IT) equipmentto support the SCMH. Funding will be processed through normal Capital Equipment

13

Expense Program channels specifically identified in support of PCMH.

b. Phase II: Recognize

All Army SCMHs will achieve NCQA Level 2 or higher recognition. Additionalinformation regarding the application process steps is included in the Army PCMHImplementation Manual.

Additionally, the SCMH must earn at least 13 points on the readiness assessment toolto be recognized as an official SCMH.

Lastly, the SCMH must have a successful staff assistance visit by the RMC using theOrganizational Inspection Program (OIP) checklist as the standard to assess currentimplementation of core principles and standards and provide assistance in meetingthese criteria.

c. Phase III: Perform

In Phase III, the clinic has achieved SCMH status. During Phase III, the practice willcontinue to close the resource gaps and implement advanced capabilities such asadvanced access and extended team member integration.

Successful SCMH practices achieve their full potential to improve the healthcareexperience by providing continuity and coordination of care, proactive population-basedhealth management, preventive and medical readiness services, and support for patientself-management.

Performance during the phase is measured by the SCMH measures of effectiveness(MOEs) and measures of performance (MOPs). These measures are discussed in moredetail in para 3-6 of this Guide.

2-2. Staffing

Successful implementation of the SCMH requires a combined commitment from boththe organic medical providers and the supporting MTF. This team effort will ensuremaximum health and readiness. As such, table 2 displays the standard SCMH staffingmodel for a BCT. The expectation is for unit providers and medics to contribute daily tothe medical needs of their Soldiers with the assets assigned to the unit. The MTFcommander has the responsibility to augment the SCMH to meet the staffingrequirements unable to be met by the supported unit. The specific requirements will bedelineated in the ISHSP. For an average BCT with its full complement of MTOEproviders, the expectation is for the brigade to provide 3-4 full-time equivalent (FTE)PCMs per normal duty day and 6-8 medics to support those providers. For non-BCTunits, the SCMH will utilize organic providers available and ratios of staff will bemodified to the number of supported Soldiers. Due to the unique operational

14

requirements of USASOC units, the daily clinical requirements of these organic militaryproviders and medics may be less than the requirements for a standard BCT.

Table 2. SCMH staffing template for one BDE or BDE equivalent

Medical Management Center

Medical Management Centers (MMCs) were created to track and facilitate the medicalmanagement of medically not ready (MRC 3B) Soldiers (OPORD 10-66). This vitalfunction is preserved in the SCMH as MMC mission and function will move intact and beintegrated into the SCMH (OPORD 12-50). Nurse case managers and care coordinatorswill continue to provide communication and coordination between the medical team andthe Soldier’s unit. Additionally, as the SCMH model matures, future analysis willdetermine if modification to the existing SCMH structure is needed to provide carecoordination services to medically not ready Soldiers.

STAFF FTE

SKILL

LEVEL

BDE (if

assigned)

Medical

Management

Center (MMC) MTF

Clinic Chief (0.3 admin, 0.7 clinical FTE)* 0.7 1 or 2 X

PCM (includes BDE Surgeon and Bn providers)* 4 1 or 2 X X

Clinical Nurse OIC (RN) 1 3 X

RN (CLIN NUR) 3 3 X X

Respect Mil Care Facilitator (RN) 0.3 3 X

Nurse Case Mgr (RN) 0.7 3 X X

Care coordinators (LPN)- 1 per 100-150 medically not ready Soldiers 3 4 X X X

Group Practice Manager (responsibilities may be covered by trained NCOIC) 0.5 5 X

68W /LPN (2 MEDICS PER FTE); Clinic NCOIC 1 68W from MTF 8 4 X X

ADMIN Assistant/Nursing Assistant/Medical Assistant/68G 2 5 X X

BH PROVIDER 1 2 X X

BH TECH- 1 per BH provideer 1 4 X X

Internal BH Consultant 1 2 X

PHARMACIST 0.5 2 X

DIETITIAN 0.5 2 X

PHYSICAL THERAPIST 2 2 X X

PHYSICAL THERAPIST TECH (1.5 per PT) 3 4 X X

68K/MED LAB TECH 1 4 X X

68Q/PHARMACY TECH 1 4 X X

68P/RADIOLOGY TECH 1 4 X X

TOTAL FTEs 35.2

included in 3.1 s upport staff per PCM FTE

*PCMs required = 1 per Bn i f as s igned OR as defined i n empanelment directives i f from MTF (Annex I, OPORD 11-20)

**Pos i tions are fi l led by ass igned staff from the BDE or BDE equiva lent as the fi rst opti on. MTF provides s taff as required to complete the staffing model .

SOLDIER CENTERED MEDICAL HOME (SCMH) STAFFING TEMPLATE FOR ONE BDE or BDE equivalent

(1BCT/Brigade Equivalant = 4000 Soldiers)

SOURCE

15

Embedded behavioral health

Per OPORD 12-63 (August 2012), EBH provides an early intervention and treatmentmodel that promotes Soldier readiness. As with SCMHs, EBH provides care to Soldiersin close proximity to their unit area and in close coordination with unit leaders. EachBCT will have its EBH NLT FY15; by FY17, all active component Soldiers in operationalunits will be supported by an EBHT.

With EBH, Soldiers receive expedited evaluations and community-level treatment froma single provider, which greatly improves continuity of care. In addition, leaders have asingle point of contact for questions regarding the BH of their Soldiers and an easilyaccessible subject matter expert (SME). The enduring working relationship between theprovider and key battalion personnel erode the stigma commonly associated with BHcare in the military setting. EBHTs will provide direct support to identified ActiveComponent operational (deployable) units under the command and control ofFORSCOM, USAREUR, USARPAC, and USASOC. The EBH organizational structure isincluded at appendix B.

2-3. Training

The following are essential training elements for the SCMH: Core Content training,Team Strategies and Tools to Enhance Performance and Patient Safety™(TeamSTEPPS™) training, Medical Applications and Process Solutions (MAPS2.0)/TriService Workflow (TSWF) training, Army Medicine Secure Messaging Service(AMSMS) training, and CarePoint and/or PCMH Huddle platforms. Training can begin inthe Prepare Phase with practice ready and trained by the end of the Recognize Phase.Sustainment and refresher training are ongoing activities to maintain the competenceand effectiveness of the practice. The SCMH must have a plan to effectively “on board”new employees with critical training elements. Additionally, SCMHs must have adetailed and coordinated plan to provide FORSCOM, USARPAC, and USAREURassigned medical personnel with orientation and MTF-specific training, as required bycurrent medical training guidance and standards.

Core Content trainingThe Army PCMH Core Content training has been developed by MEDCOM and willbe provided by the RMC Transformation Teams. Training modules are aggregatedinto two multi-day blocks of training: Step 1 and Step 2. Steps 1 and 2 can becompleted in separate training sessions or in one combined session. Training is notrestricted to primary care staff; it is also intended for department and brigade levelleaders from medical and administrative areas within the organization. Initial andsustainment training resources include the Army PCMH Interactive Multi-MediaInstruction Suite produced through the Army Medical Department Center and Schooland available on line or by DVD.

TeamSTEPPS trainingTeamSTEPPS training is essential to enhanced care team performance and patient

16

safety. TeamSTEPPS training requirements are defined in MEDCOM OPORD 11-38at the Office of Quality Management Web site:https://www.qmo.amedd.army.mil/ptsafety/TeamSTEPPS.htm4.

MAPS 2.0/TSWF trainingLeaders must ensure all clinical team members in the SCMH are properly trained inthe standard workflow processes and tools included in the MAPS 2.0 program, andthat all necessary infrastructure, hardware, and software are available andfunctioning at peak performance. MAPS 2.0 using TSWF is an essential componentof patient-centered workflow. TriService Workflow Alternate Input Method (TSWFAIM) templates for AHLTA with partnered MAPS tools are the requireddocumentation tools used in the SCMH. Adherence to the MAPS 2.0 standardprogram is monitored and enforced locally.

CarePoint/PCMH huddle toolLeaders will ensure that all staff in the SCMH responsible for huddle preparationhave a Carepoint account and receive adequate training on the use of the HuddleTool. Requests for Carepoint access are initiated through the MEDCOM EvidenceBased Practice office at (210) 221-6527.

Army Medicine Secure Messaging ServiceArmy Medicine Secure Messaging Service (AMSMS) is a suite of capabilitiesintended to reduce reliance on telephonic patient communications and to replacesome face-to-face visits related to chronic disease management. AMSMS is asecure system allowing for communication between the patient and one or moremembers of their care team, as well as between members of the care team andoutside consultants involved in the patient’s care. AMSMS is intended to be theprimary means of communicating with patients and team members.

2-4. Facilities and information technology

The SCMH must be located in close proximity (ideally within walking distance) to theSoldiers’ primary work area. SCMHs will be located within a Joint Commission surveyeligible CAT 500 building owned and operated by the MTF command. Exceptions to theCAT 500 requirement may be approved by MEDCOM, but the facility must meet thecriteria in MEDCOM policy 13-23. The MTF will ensure that SCMHs meet the two-exam-room-per-provider-readiness criteria and optimize facility utilization. Funding for facilitymodification projects will come out of core SRM funds.

SCMHs will also include basic laboratory and pharmacy capability as well as dedicatedareas for PTs. Although the intent is for the physical therapy capabilities to be locatedwithin the SCMH, if logistically and fiscally indicated, physical therapy resources may becombined in a nearby, co-located position to benefit more than one Home.

SCMHs will also include the needed IT infrastructure to utilize AHTLA, MAPS 2.0, andweb connectivity. The regional information management and information technology

17

(IMIT) POC will coordinate with the MTF IMIT personnel to determine the neededupgrades and coordinate funding requests.

2-5. Installation Specific Health Services Plan and the Senior Medical Council

Each Installation will comply with DA EXORD 15-10 and develop an ISHSP. Inconjunction with the ISHSP, the Installation Senior Medical Council will be the primarymechanism to coordinate line and MTF medical leadership and clinic issues for theSCMH.

18

CHAPTER THREEOPERATIONS

3-1. Soldier patient workflow

The SCMH is the primary home for all Soldier medical needs. The SCMH is specificallydesigned to provide comprehensive primary care and clinical pharmacy, physicaltherapy, nutrition care, behavioral health, case management, and care coordination.The SCMH will be located in close proximity to the Soldier’s primary work area. Triageand Algorithm Directed Troop Medical Care (ADTMC) (see MEDCOM Pamphlet 40-7-21) may still occur at the unit aid station, but any medical needs exceeding triage willtake place in the SCMH in accordance with the policies described in this Guide and thePCMH Implementation and Operations Manuals and the associated annexes. All clinicalwork hours will be recorded into the Defense Medical Human Resources Systemsinternet (DMHRSi).

The unit medical staff will provide care for their assigned Soldiers during normal dutyhours. The brigade and battalion surgeons, along with their two medics, will each serveas the PCM core team for their Soldiers. Collectively, all the brigade providers serve asthe PCM Home. Medics working in the SCMH will practice to the full level of theircompetencies as detailed in the PCMH core competency matrix.

As with the PCMH, care requiring services or personnel unavailable (at the SCMH) willbe referred to the MTF. Consult reports and pertinent laboratory and radiographicstudies will be sent to the PCM to ensure care coordination for the Soldiers.

Medical readiness is a joint responsibility between the operational medical section andthe MTF-provided SCMH staff. As such, the unit’s medical team will use both its clinicaland administrative members in partnership with the SCMH to ensure that both themedical readiness requirements and reporting requirements are met.

3-2. Roles and responsibilities

All privileged providers are required to meet relevant MEDCOM reporting and qualityassurance measures. Non-privileged personnel will not provide unsupervised garrisonhealth care in any capacity. Non-privileged personnel may perform screening,immunizations, and readiness activities under the supervision of a privileged provider(subject to documentation of appropriate training/skills validation and maintenance ofnecessary certifications). All provision of health care must remain within the acceptablescope of practice/competency for that provider’s/practitioner’s military occupationalspecialty/area of concentration.

19

3-3. Huddle

The huddle is an essential element to coordinated team-based care. Each morningbegins with a huddle following the standard checklist detailed in the huddle trainingmodule and video (see core content).

3-4. Non-face-to-face care

To maximize patient access and most efficiently utilize the SCMH staff, all members ofthe SCMH team will reinforce the benefits of virtual care and utilize face-to-face visitsonly when needed. AMSMS, TRICARE Online, telephone consults, and telephonicnurse advice lines provide patients easy and secure methods to communicate with theircare teams.

3-5. Care coordination, transitions in care, and case management

As the SCMH is the home for the Soldier's medical needs, the PCM and core team areresponsible for the care coordination with interdisciplinary team members (e.g.,nutritionist, clinical pharmacist), and with providers in the network. The SCMH team alsoensures transitions of care is managed through active collaboration and coordination ofthe Soldier's transfers between different locations (Medical Home to inpatient) orbetween levels of care within the same location (ICU to the ward). This coordinationensures our Soldiers have no break in care or services. Key in this process is the role ofthe case manager; the SCMH case manager provides dedicated case managementcapabilities to Soldiers with complex medical needs as well as those who are currentlymedically not ready.

3-6. Performance standards

MEDCOM evaluates all SCMH practices on the standard PCMH performancemeasures. These metrics are divided into two elements: MOPs and MOEs. Table 3 liststhese metrics; each region briefs the MOEs to the Deputy Commanding General forOperations on a rotating 6-week cycle.

20

ARMY PCMH KEY PERFORMANCE MEASURE DICTIONARY (MOPs)

MEASUREOPERATIONAL

DEFINITIONAMBER

THRESHOLDGREEN

THRESHOHLD

MTFTO

RMC

RMC TOMEDCOM

Number ofConvertedPractices

# of practices that havemet the three criteria foran ARMY PCMH w/180days

<210 Days <180 Days M M

2 Exam Rooms PerPCM

Optimize space toprovide 2 exam roomsper available providerFTE

1.8 per PCMHFTE

2 per PCM FTE M M

MAP 2.0Implementation ofOPORD 11-47

Phase IIcomplete, III

partiallycomplete

Phase IIIcomplete

M M

4th Level MEPRSImplementation

Activate and implement4th Level MEPRS

MEPRS coderequest

approved byAMPO

MEPRS codeactive in CHCS,DMHRSI, and

EASIV

W W

SAV CompletedStaff assistance visitconducted by the RMCusing the OIP Tool

Datescheduled tooccur beforeNCQA surveysubmission

Completedbefore NCQA

surveysubmission

NA M

NCQA RecognitionNCQA-recognizedLevel 2 within 180 daysof license issue

NCQA Surveysubmitted

Level 2Recognition

M M

Staff Hired to GapAnalysis

% of PCMH staff hiredto total practicerequirements

>80% >90% M M

21

ARMY PCMH KEY PERFORMANCE MEASURE DICTIONARY (MOEs)

MEASUREOPERATIONAL

DEFINITIONAMBER

THRESHOLDGREEN

THRESHOHLD

MTFTO

RMC

RMC TOMEDCOM

Enrolled toCapacity

Per enrollment capacitymodel (ECM)- #enrollees per availablePCM FTEs

5-10%above/below

capacity

< 5% above orbelow PCM

CapacityM M

ER Utilization# of visits to the ER per100 enrollees permonth

40-50 <40 M M

Primary CareLeakage

Primary care RVUscompleted in networkcompared with totalprimary care RVUs forenrollees

3-5% <3% M M

PCM Continuity

Primary care visits(ACUT, OPAC,WELL,EST, ROUT, and PCM)where the patient sawtheir assigned PCM

55% -64% >64% M M

PatientSatisfaction

Patient satisfaction withoverall clinic visit (Q20)

90-95% 95% M M

Staff Satisfaction

Staff satisfactionreported in theMEDCOM SpeaksPCMH/CBMHEmployee EngagementIndex

>63% >67% Q Q

HEDISTM

Composite

Composite of eightNCQA health serviceperformance metrics:screening for cervicalcancer, breast cancer,colon cancer,chlamydia; diabetes x3,asthma control

60-87.5%Composite

score – 24/40= 60% (points

per metricbased onpercentile)

>87.5%Composite

score – 35/40 =87.5% (points

per metricbased onpercentile)

M M

Medical Readiness(MRC4)

Soldier that has not hada PHA within the past12 mos.

5-8% <5% M M

Medical Readiness(MRC3b)

Non medically readydeployable Soldier withduration > 30 days

5-8% <5% M M

MEB PhaseTimeline (days)

Time in MEB phase(days from MEB referraluntil MEB end)

100-160 days <100 days M M

BH AdmissionRate

# of BH admissions indirect and purchasedcare systems

31-50/1000 <30/1000 M M

22

Polypharmacy

% of Soldiersprescribed 4 or moremedication with onebeing a psychotropic orCNS depressant

TBD TBD M M

No Show Rate (PC,BH, PT)

Soldier no-show ratesfor primary care, IBHC,or physical therapy

6-10% <6% M M

PracticeManagementRevenue Model(PMRM)

Measures practiceproductivity (workloadrevenue / availablepractice FTEs) on a perprovider basis.

$314,000-275,000

>$314,000 M M

Table 3. Measures of performance and measures of effectiveness

23

APPENDIX ALocation of Soldier Centered Medical Homes

The following image identifies the location of all 41 current and future SCMH Practices.The 11 SCMH proofs of concept sites are identified by the gold stars. Per OPORD 12-50, all Army SCMHs will be fully functional by FY15 (except for TRADOC and USASOCSoldiers). During phase V of the OPORD, SCMHs will be developed for theseCommands.

24

APPENDIX BEBH Structure

The structure of the EBH is contained in the following diagram:

The EBH, internal behavioral health consultant (IBHC), and SCMH closely coordinatecare to the Soldiers assigned to the SCMH. The IBHC and the providers in the SCMHutilize the EBH physician for co-management of complex cases and facilitation of properpharmacologic management. In contrast to the IBHC, the EBH is not organizationallyaligned under the SCMH; therefore, EBH personnel are not rated by the SCMH staff.