Patient Centered Medical Home

[upchit]

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Hi all,

I'd like to start a thread about the patient centered medical home (or, in the Navy "Medical Home Port/ Fleet Centered Medical Home"). I am in the middle of implementing this (because thats clearly a collateral that a physician has time to take on 🙄)... and trying to find some "best practices" or tips from any other docs who have worked in a military med home?

So far, we are struggling with getting our staff up to speed to perform at the "top" of their license/skill set, and struggling with red tape to get mobile charting (i.e. wireless internet and laptops with AHLTA).

Some of the future challenges I see are:
- How do you prevent an overwhelming rush of patients when you declare: "if you want to be seen the same day you will be seen the same day"
- How did you negotiate a switch from a traditional "sick call" to scheduled appointments and how did tenant commands do with the switch?
- How did you deal with the mass influx of emails from the relay health system? Do you have nurses or corpsmen answer them or do you do it yourself?

Thanks in advance to all. I'll try to share any valuable gouge as I get it too.

 

[orbitsurgMD]

Who are you? Are you a physician?

 

[NavyFP]

While I am a fan of Med Home, it is a farce.

Same days - not going to happen all the time. Do NOT do open access. Claim you are and the don't.

Sick Call - This is a duty issue. Can you work today? Leave open the first 45 min to hour and have 15 minute appointments and have your corpsman triage. If it is not an issue about going to work today, it can wait until later. One problem only and everything else they need to come back for. Routine issues are not allowed. Commands actually like appointment for sick call because it means they have a time when they can expect their people back. I implemented a system like this years ago at Pearl Harbor. We went from long lines taking all morning for sick call to having them all out in by 0830. It eliminated the sick call commando who checked in one minute prior to the deadline and hung around all morning.

Relay health was not a huge problem for me when I was on it. It can work great for refills and lab followups.

The biggest problem you will have it inappropriate booking by call centers. They will book outside of teams and fill up same days with non-same day stuff. I added time to my providers schedules for same days that were not on the books as appointments. This gave the team nurses some flexibility.

 

[244913]

Hi all,

I'd like to start a thread about the patient centered medical home (or, in the Navy "Medical Home Port/ Fleet Centered Medical Home"). I am in the middle of implementing this (because thats clearly a collateral that a physician has time to take on 🙄)... and trying to find some "best practices" or tips from any other docs who have worked in a military med home?

So far, we are struggling with getting our staff up to speed to perform at the "top" of their license/skill set, and struggling with red tape to get mobile charting (i.e. wireless internet and laptops with AHLTA).

Some of the future challenges I see are:
- How do you prevent an overwhelming rush of patients when you declare: "if you want to be seen the same day you will be seen the same day"
- How did you negotiate a switch from a traditional "sick call" to scheduled appointments and how did tenant commands do with the switch?
- How did you deal with the mass influx of emails from the relay health system? Do you have nurses or corpsmen answer them or do you do it yourself?

Thanks in advance to all. I'll try to share any valuable gouge as I get it too.

We were just beginning to deal with this when I got out.

To me "patient centered medical home" is a euphemism for removing authority from line physicians and their medics and giving it to bean counters in the clinics ie. nurses, MSC's and other types. A frequent occurrence in the medical corps- total responsibility without any authority.

It also reflects the continued empowerment of patients at the expense of Physicians and others who oversee their care. Patients really do not know what is best for them, in spite of what the nurse corps would tell you. In the military unfortunately there is a small minority in any unit who abuse the system to get out of work, avoid duty, and commit disability fraud. These scoundrels will leverage this new arrangement for all it's worth, and wreak havoc on the Line's already stretched medical resources.

It was a mess when I left- flight docs had no control over their schedules, patients could call an appointment line and book directly into a timeslot whenever they pleased, for the most trivial of conditions or non-conditions that previously would have been well managed or screened out completely at the sick call level. It also made the medics feel useless because they didn't have a job to do. Finally, docs were seeing patients from other units and this was destroying continuity of care and greatly disrupting unit medical readiness.

Luckily I got out before it became a reality. I'm sure it will be a colossal failure and there will be some readjusting. The fact of the matter is that on the operational side, patients have extraordinary ease of access to services- I'd see them same day for toe fungus, disability paperwork, profiles. In my squadron, no one ever had to wait more than 24 hours for an appt. Most of my buddies and all the Officers had my cell phone number.

I'm sorry I don't have any concrete advice. Your post just reminded me of what a fiasco I perceived this deal to be and how glad I am to be out before it was fully implemented.

ex 61N

 

[155HE]

Hi all,

I'd like to start a thread about the patient centered medical home (or, in the Navy "Medical Home Port/ Fleet Centered Medical Home"). I am in the middle of implementing this (because thats clearly a collateral that a physician has time to take on 🙄)... and trying to find some "best practices" or tips from any other docs who have worked in a military med home?

So far, we are struggling with getting our staff up to speed to perform at the "top" of their license/skill set, and struggling with red tape to get mobile charting (i.e. wireless internet and laptops with AHLTA).

Some of the future challenges I see are:
- How do you prevent an overwhelming rush of patients when you declare: "if you want to be seen the same day you will be seen the same day"
- How did you negotiate a switch from a traditional "sick call" to scheduled appointments and how did tenant commands do with the switch?
- How did you deal with the mass influx of emails from the relay health system? Do you have nurses or corpsmen answer them or do you do it yourself?

Thanks in advance to all. I'll try to share any valuable gouge as I get it too.

The term "Patient Centered Medical Home" brings back some awful memories. I had to deal with this in III MEF when I was a GMO... We were directed by TMO to set up mini Marine Centered Medical Homes in garrison, but we were also told by the "founder" of Medical Home (who is now the CO of NH Pensacola) that we would receive little in the way of funding to help us do this.

To respond to some of your questions/comments...

1. I doubt you will get mobile charting capability. Well maybe right after the Navy fills all GMO billets with BC/BE physicians. Which means it will never happen.
2. Once we switched to an appointment-only system, we never experienced a rush of patients wanting to be seen the same day. Actually, there was a surprising amount of positive feedback to the appointment system. In our clinic, Corpsmen were responsible for answering the phones and doing a lot of the scheduling. In that capacity, training them to do some telephone triage did a lot to ensure that people who needed to be seen the same day were, and people who didn't need to be seen the same day didn't.
2. My command seemed to deal with the switch relatively well. It was an easy sell to the officers. The SNCOs and NCOs needed a bit more convincing, so I had several Q/A sessions before the implementation went forward. The main benefit to the appointment-only system was that Marines didn't hang around for hours in sick call in the mornings. Their main concern was that their sick Marines wouldn't be able to be seen on a timely basis, which ended up not being an issue once the appointment-only system was implemented.
3. Relay health was not set up on Green-side, so I cannot comment on it.

I had a love-hate relationship with MCMH. On one hand, I lost the autonomy that I had in my own BAS (which had to be shut down by order of the MEF surgeon at the time in order to start MCMH). I also agree with 61November--medical home starting become a system where all of a sudden the clinic OIC (a blue-side Nurse Corps officer) was in my business, telling me how to run my schedule, how to arrange my spaces, etc. Even though I technically was only responsible to my Marine CO, I now had to deal with a Nurse, who was not in my chain of command. I really did not appreciate this loss of autonomy.

On the other hand, the appointment-only system made my clinic schedule more predictable. On days where I had personal stuff to take care of, or meetings, or when I went on leave, there were other GMOs in the clinic that could handle the workload, rather than my Marines waiting for me to come back from whatever I was doing...patient care could continue in my absence (something that the Marines sometimes forget).

I went to residency before many of the major changes took place. Now I don't have to see patients, and life is much easier...one of the nice aspects of Rads.

 

[155HE]

Thanks for the replies.

OrbitSurg, yes I am a flight surgeon in a BSO-18 billet, which is why I am dealing with Med Home issues.

I appreciate the feedback from NavyFP, 155HE, and 61November.

Yes, it is a huge difference from how things used to run, especially on the aviation side. We already have problems with the call center booking a patient with whomever the patient says he/she wants to see. Which creates a huge problem when you book aviators with our IDC's for sick call and you book ground guys with me. No matter what we tell the call center this always happens which results in us re-arranging patients or me having to curbside consult on a bunch of other patients that non-FS's are seeing to determine disposition.

It is reassuring that we all have had the same problems, I have a year left in this billet and I'm trying to get through, so trying to make all of this work and help in any way I can.

We do have the Nurses telling us we must see any patient the same day AND address all of their concerns in one visit. My record is 10 separate complaints. I usually ask for the top 2 complaints during the appointment and then ask the patient to leave and come back to spend my lunch or an hour after the end of clinic seeing the patient for the remainder of the complaints. I honestly don't know how they want us to address all complaints and still stay on time with 20 minute appointments. Most of my complicated patients are my wounded warriors and I can't in good conscience tell them to come back another day. I have asked if we can adjust templates so I have hour long appointments with more complicated patients and I was told to be more efficient with my 20 minute appointments. Any suggestions for this problem?

Also, as an aside, have any of you figured out a way to code for time spent writing Narrative summaries for MEBs/PEBs? I know we can code specifically for home health paperwork but I spend hours writing NARSUMs and have never found a way to get "credit" for that time in AHLTA.

Thanks again.

.

 

[upchit]

Hi 155HE,

Your points are well taken and I feel empowered and a bit disabused from your comments. My goal in coding accurate workload is to hopefully reflect how short staffed my clinic is, and I'm told by the nurses that RVUs are how this is calculated. So, for the sake of the FS's who will come after me to this location, I'm trying to make the case for more doctors here. I don't really care about the monetary equivalent of my work or my fitrep at this point.

We have been told, either get on board with med home or hit the road, so I don't suppose that's a battle worth fighting. I am under the BSO18 billet so my fitrep is written by an MTF CO, and the line squadrons are supportive but ultimately don't own me. I've lost the battle for 50/50 time, even with line commanders making calls so I think that is a futile goal as well.

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Anyway, I appreciate the advice and any further suggestions are welcome.