Air Force News, news from Iraq - Air Force Times

Air Force is taking team approach to health

When Senior Master Sgt. Brad Johnson learned he had a life-threatening autoimmune disorder, he began spending more time than he ever thought possible at the doctor’s office.

But Johnson never knew which doctor he would see for any given appointment — and spent hours explaining and re-explaining his case.

Today, several years later, Johnson sees the same doctor and nurse every time, a change that came about by virtue of simply where he’s stationed. Ellsworth Air Force Base, S.D., is one of 10 bases that have implemented a revolutionary program that will be introduced Air Force-wide over the next two years.

“I can call [the doctor and nurse] at any time and they know exactly what I’m saying ... and where to take my treatment from there,” said Johnson, superintendent of the 28th Maintenance Squadron. “They understand you and your body, not just what the test results are telling them.”

The Family Health Initiative — limited right now to base family health clinics, though pediatrics could be included later — keys in on the personal relationship between patient and provider, creating what one of the service’s top doctors says is greater continuity of care.

Building rapport with a medical team — doctor, nurse and technician — will put the focus “more on preventive, proactive care instead of reactive care,” leading ultimately to healthier airmen and their families, said Lt. Col. (Dr.) Tim Kosmatka, chief consultant for family medicine services at the Air Force Medical Operations Agency in San Antonio.

While it is too early to declare the program an unqualified success, Kostmatka is encouraged by what he has seen so far.

Two of the participating bases — Scott Air Force Base, Ill., and Andrews Air Force Base, Md. — have dramatically improved their national standings in such areas as cost containment, patient satisfaction, access to care and quality of care. Scott had outperformed about 65 percent of health care practices nationwide; now, its medical teams are performing at 80 percent or better, putting it in the top fifth of the U.S. clinics. Andrews, too, was at 65 percent; today, the base’s teams are at 75 percent or better, placing it in the top 25 percent of health care centers nationwide.

Besides Scott, Andrews and Ellsworth, the other locations are Edwards Air Force Base, Calif.; Misawa Air Base, Japan; Patrick Air Force Base, Fla.; F.E. Warren Air Force Base, Wyo.; Bolling Air Force Base, Washington, D.C.; Hill Air Force Base, Utah; and Sheppard Air Force Base, Texas.

Implementing the program before the end of the year will be Laughlin Air Force Base, Texas; Elmendorf Air Force Base, Alaska; and RAF Lakenheath, England. Twenty more bases will join next year, though the sites cannot be made public yet because they’re still in the process of being approved, Kosmatka said.

The Family Health Initiative, launched in August 2008 at Ellsworth and Edwards, is modeled on the patient-centered medical home, a 1960s concept that is making a comeback as the nation struggles to make health care more efficient.

A patient-centered model — a primary-care doctor, nurse and technicians who work as a team — provides treatment for most conditions and makes referrals to specialists judiciously.

The model has the support of the American Medical Association, the American Academy of Family Physicians and other national health care groups.

“The patient-centered medical home is really about providing that personalized, continuous care that is comprehensive,” said Dr. Lori Heim, a retired Air Force colonel who is president-elect of AAFP. We’re “trying to refocus [care] on what does the patient need and providing care through a team approach.”

Under the Air Force program, a team consists of a doctor, physician assistant, nurse and five medical technicians.

“These providers are trained to provide a broad level of care … as opposed to … where it’s very fragmented care where you see specialists for most of your problems,” Kosmatka explained.

Many civilian doctors, for example, would refer a teenager with acne to a dermatologist even though they’re qualified to treat the condition, he said.

Under the military health care system, seeing a specialist often requires being referred to a civilian provider through the Tricare system; those appointments are often hard to get quickly for the patient and expensive for the military. The initiative will probably result in fewer Tricare referrals.

The impetus behind the patient-centered medical home movement in the civilian sector is cost savings, Kosmatka said, but in the military — the other services are also implementing the concept — the primary goals are improved doctor-patient relationships, better access to treatment and higher quality care itself. The Air Force hopes to save money but sees cost-cutting as a side benefit, he said.

Studies show patients cared for by a medical home team need fewer appointments because they trust their providers more and health problems can be prevented or treated with fewer visits, Kosmatka said.

While the program is still too new to show conclusive results, Kosmatka said the participating bases are already reporting a decrease in demand for appointments, which frees up doctors and reduces wait times for patients.

Johnson, who has the autoimmune disorder, has been able to see his doctor much more quickly under the new initiative.

“It’s a night-and-day difference for me,” he said. “It is very easy for me to get in. I call up and I’m seen very quickly.”

The initiative is also improving access by reducing the patient-to-doctor ratio. Once 1,500 patients for one doctor, the new system decreases the number of patients to 1,250.

“They’re going to have more ability to give good care for that smaller number,” Kosmatka said.

The key to providing better care is having patients consistently see the same providers, said Maj. (Dr.) Cecelia Ficek, director of the family medicine clinic at Ellsworth.

“The nice part is we know the patients inside and out,” said Ficek, who is Johnson’s doctor. “My [assistant] knows the cases very well too, so she communicates with [patients] just as much as I do. … Even something that’s a difficult task to do, we can accomplish it … because we can effectively communicate. [The other team members] know the case just as well as I do so they can help coordinate care.”

Before the initiative, patients at Edwards saw their primary physician no more than 70 percent of the time; their counterparts at Ellsworth didn’t fare as well, only about 60 percent of the time. Now, numbers for both bases are about 20 percent higher.

Providers also can practice more preventive medicine when they know their patients better. Again, it is difficult to determine the success of preventive measures so early in the program, but Kosmatka sees the drop in demand at some of the bases as an indication that patients are healthier.

With the Family Health Initiative, the Air Force hopes to keep more of its doctors and nurses, in turn improving its ability to provide higher-quality care.

Some Air Force health care providers attribute the low retention in part to a poor working environment.

Under the old model, Ficek arrived at work every day to face a full slate of patients, many of whom she had never seen before. She also didn’t consistently work with the same nurses and technicians, which made communication more difficult and the environment less enjoyable, she said.

Now, she has a team to work with, gets to know her patients well and schedules her appointments in a way that she believes makes the best use of her time.

“For me, just having the ability to see patients on my [schedule], what is most efficient for me, is very helpful,” Ficek said. “It really enables me to time manage better, to see those complicated patients and to feel like you’re giving them an adequate amount of time.”

Kosmatka knows of at least two doctors who were planning to leave the Air Force but have decided to stay in part because of the Family Health Initiative.

“We need to create an environment that people want to practice in,” he said.

“It’s certainly what … drew me into family medicine — getting in touch with your patients and that relationship aspect.”

Manning is the biggest hurdle that the program at Ellsworth has faced, Ficek said.

The base’s medical home teams are not fully staffed with medical technicians, and one doctor is deployed and another is on maternity leave. Their absence interrupts the patients’ continuity of care and forces other providers to pick up the slack.

Heim, with the American Academy of Family Physicians, points out such difficulties are to be expected.

“What we have learned is that you’re really talking about a change, and change is very difficult,” she said. “This is not an easy task. They should be applauded for trying it.”