Department

of

Defense

Population Health

Improvement

Plan and Guide

DoD TRICARE Management Activity

December 2001
“It is a distortion, with

something profoundly

disloyal about it, to picture the human being as a

teetering, fallible contraption, always needing,

watching and patching,

always on the verge of

flapping to pieces.”

Lewis Thomas, The Lives

of a Cell, 1974

Suggested Citation Suggested Citation

DoD TRICARE Management Activity DoD TRICARE Management Activity, Population Health Improvement Plan

and Guide and Guide, Washington D.C.: TRICARE Management Activity ashington D.C.: TRICARE Management Activity, Government , Government

Printing Office. 2001 Printing Office. 2001

For more information about the DoD Population Health Improvement Plan and For more information about the DoD Population Health Improvement Plan and

Guide or to access Population Health documents online, visit: Guide or to access Population Health documents online, visit: Guide or to access Population Health documents online, visit:

http://www.tricare.osd.mil/mhsophsc/DoD_PHI_Plan_Guide.pdf
i

Foreword
ii

Acknowledgments

The DoD Population Health Improvement Plan and Guide was prepared under

the supervision of the Military Health System (MHS) Population Health Integration Team, with oversight provided by the MHS Optimization Team. This first

edition of the Plan and Guide is an expansion of the draft Population Health

Improvement Plan and Guide written by the MHS Population Health Working

Group and released in April 2000. Experts from the Center for Health Promotion

and Preventive Medicine (CHPPM, U.S. Army), Navy Environmental Health

Center (NEHC, U.S. Navy), Population Health Support Directorate (PHSD, U.S.

Air Force) and Office of the Special Assistant for Optimization, TRICARE

Management Activity, contributed valuable direction, content and technical

assistance for writing this edition. A special thanks is extended to the many

people across the MHS who critically reviewed the final draft.

Kelly Woodward, Lt Col, USAF, MC

Editor

Sharon Sebbio, CAPT, NC, USN

Assistant Editor

Bruce Weaver, Lt Col, USAF, BSC

Assistant Editor

MHS Optimization Team

John Aguilar, CAPT, MC, USN

Charlie Davis, CAPT, MC, USN

Sean Murphy, Col, USAF, MC

Bob Opsut, PhD, OASD(HA)

Timothy Williamson, COL, MS, USA

MHS Population Health Integration

Team

Lucretia McClenney, COL, AN, USA

Sharon Sebbio, CAPT, NC, USN

Rosa Stith, COL, MC, USA

Lei Jones, Lt Col, USAF, NC

Robert Wah, CDR, MC, USN

Bruce Weaver, Lt Col, USAF, BSC

Kelly Woodward, Lt Col, USAF, MC

MHS Population Health Working

Group

Sandra Wilcox, COL, MC, USA

Vic Eilenfield, LTC, MS, USA

Dorothy Smith, LTC, MS, USA

Sharon Pacchianna, MAJ, MS, USA

Charlie Davis, CAPT, MC, USN

Paul Hoffman, CAPT, MSC, USN

Marsha Beaugrand, CDR, MSC, USN

Jan Carrio, CDR, NC, USN

John Chandler, CDR, MC, USN

Greg Haugan, CDR, MSC, USN

Steve Wyrsch, LCDR, NC, USN

Jim Fraser, Col (ret), USAF, BSC

Mike Spatz, Col, USAF, MC

Brian Masterson, Lt Col, USAF, MC

Arnyce Pock, Lt Col, USAF, MC

Pequitte Schwerin, Lt Col, USAF, NC

Susan Fisk, Maj, USAF, NC
iii

Table of Contents

Foreword ................................................................................................................................................................................................... i

Acknowledgments .................................................................................................................................................................................... ii

Table of Contents .................................................................................................................................................................................... iii

Executive Summary ................................................................................................................................................................................ iv

Population Health Improvement Plan and Guide ................................................................................................................................... 1

Introduction ............................................................................................................................................................................................. 1

Population Health Improvement and the Military Health System (MHS) Optimization Plan .................................................1

How to Use This Plan & Guide ...................................................................................................................................................2

Summary of the Sections.......................................................................................................................................................................... 3

Section I. Overview of Population Health Improvement.......................................................................................................................... 5

A Conceptual Framework for Population Health Improvement ................................................................................................5

Making Population Health Improvement a Reality in Department of Defense ......................................................................12

References ................................................................................................................................................................................. 25

Section II. Force Health Protection ........................................................................................................................................................27

Section III. Worksite and Community-based Programs ........................................................................................................................ 29

Scope ........................................................................................................................................................................................ 29

Examples of Interventions ....................................................................................................................................................... 29

Service Resources ..................................................................................................................................................................... 30

Reference ..................................................................................................................................................................................30

Section IV. Military Treatment Facility Implementation Guide .............................................................................................................31

Military Treatment Facility Population Health Offices ............................................................................................................ 31

Introduction to MTF Key Process Elements .............................................................................................................................31

Identify the Population ............................................................................................................................................................ 35

Forecast Demand ......................................................................................................................................................................39

Manage Demand ......................................................................................................................................................................43

Manage Capacity ......................................................................................................................................................................49

Evidence-Based Primary, Secondary, and Tertiary Prevention ................................................................................................ 55

Community Outreach .............................................................................................................................................................. 63

Analyze Performance and Health Status ..................................................................................................................................67

Section V. Regional Population Health Offices .......................................................................................................................................73

Concept ..................................................................................................................................................................................... 73

Functions ..................................................................................................................................................................................73

Roles .........................................................................................................................................................................................74

Section VI. Military Health System Optimization & Population Health Support Center (OPHSC) ...................................................... 75

Concept ..................................................................................................................................................................................... 75

Functions ..................................................................................................................................................................................75

Section VII. Tables of Population Health Key Process Element Tools .................................................................................................... 79
iv

Executive Summary

The Military Health System (MHS)

mission is to provide health services to

the full range of military deployments

and to maintain the health of

members of the armed forces, their

families and others. This can be

accomplished through the MHS goals

to protect military forces from

medical threats, employ a comprehensive health plan, use health

promotion and prevention, and

optimize clinical outcomes. The

MHS, however, is a large and unique

integrated health system that is part

of the larger Department of Defense

(DoD) and all its surrounding

communities. Within the MHS, DoD

and surrounding communities, are

those programs and activities that can

be employed to improve the health of

military communities; Force Health

Protection, worksite and communitybased, and TRICARE health plan

programs. Programs in each of these

areas contribute to the DoD strategy

for population health improvement.

Population health improvement

(PHI) is the balancing of awareness,

education, prevention and intervention activities required to improve the

health of a specified population. This

model unites self-care, MTF, worksite

and community-based wellness and

prevention activities and medical

interventions into a comprehensive

paradigm centered on primary,

secondary, and tertiary prevention to

reduce morbidity and premature

mortality and improve health. These

activities, in concert with strategies

that optimize the appropriate use of

health services, can reduce the gap

that exists between forecasted demand

and the capacity currently within the

health care system. The strategies are

to modify personal disease and injury

risk, effectively change behaviors to

optimize health and enhance fitness,

allow health services providers to

render necessary care while reducing

unwarranted treatment variation, and

achieve measurable improvements in

performance and health status. This

broad scope of activities and strategies

is the responsibility of the DoD and,

more specifically, the MHS.

Department of Defense activities for

population health improvement are

in three areas: Force Health Protection, worksite and community-based

programs, and TRICARE health plan

programs. These programs are

combined in DoD to cover the core

functions of public health, health care

services of large managed health

plans and military-unique operations.

The balance of health improvement

activities within these areas should

address those factors that influence

health—the determinants of health.

Determinants such as individual

behaviors and the physical and social

environment must be addressed in

DoD programs, as well as access to

traditional health care services. Also,

interventions must be balanced to

target the most health impacting

determinants through comprehensive

primary, secondary and tertiary

prevention strategies.

Making population health improvement a reality in the DoD requires

that a systematic approach be taken

for population health improvement.

Community health planning, policymaking and programming must be

methodical and ongoing. Plans,
v

policies and programs must reflect

sound population health principles.

The first principle is to explicitly

define the populations targeted for

interventions. Next, the use of applied

epidemiology should drive the

identification of community health

problems, their risk factors and

appropriate interventions. The

interventions chosen should be

evidence-based clinical and business

interventions to ensure the best health

outcomes that are also the most costeffective. The greatest positive impact

on population health will come from

programs that leverage evidencebased primary, secondary and tertiary

prevention strategies that emphasize

primary disease and injury prevention

and early diagnosis whenever possible

and treatment and rehabilitation

when necessary. The fourth principle

is to manage information to support

ongoing health status assessment,

planning, and performance monitoring and improvement. Actionable

information must be provided to all

levels of the organization—providers,

MTFs, Regional Lead Agent offices,

Managed Care Support Contractors

and Service Headquarters. Finally,

knowledge about what works and how

to do it must be managed to ensure

thorough analysis and dissemination

to all functional units in DoD.

Plans, policies and programs are

effective only when the right resources

are in place to implement them. The

DoD must build the capacity to

implement population health

improvement initiatives. Health

promotion and disease and injury

prevention programs require renewed

emphasis. Primary care capacity

must be sufficient to ensure clinical

preventive services can be delivered.

The increasing need for health data

collection, analysis and interpretation

drives new functions in DoD health

programs. As population health

improvement activities mature, many

traditional programs such as

Utilization Management will be

integrated into population health

improvement processes and will not

continue as separate entities.

Planning and programming for the

broad portfolio of health programs

affecting military communities is

complex. Increasing technology and

service costs and increasing demands

for health services mean priority

needs typically exceed available

resources. And, like other large

health systems, the MHS must

continually improve health services

while achieving greater efficiency. To

this end, the MHS Optimization Plan

was drafted to outline the key tasks

that, if coordinated and integrated,

will improve the quality and costeffectiveness of services provided by

the MHS. A cornerstone of the

Optimization Plan is its focus on

population health. The population

health imperative is to develop and

implement a plan and model to

“optimize clinical outcomes across

the MHS” and improve health by

shifting from an emphasis on disease

and injury intervention to prevention

and health promotion.

The DoD Population Health Improvement Plan and Guide provides the

conceptual framework for improving

the health of populations and will

guide users to specific actions and

tools that will help to build healthy

communities. It also provides

guidance in support of a uniform

health care system based on systematic clinical and business decision

processes. The PHI Plan and Guide

includes an extensive catalogue and

links to offices and tools to support

the implementation of population

health initiatives. It is the resource

that will ensure fidelity to sound

population health principles and

processes and bring unity of effort to

achieve population health improvement to all military communities.

This document is divided into several

parts that cover the breadth of a

framework and the principles of

population health improvement and

the depth of implementation concepts, processes and tools. The

introduction describes how the PHI

Plan and Guide was chartered by the

MHS Optimization Plan. It also

introduces readers to the sections of

the Plan so they can easily navigate to

those sections they want to read now

and those they want to return to later.

Section I provides a comprehensive

strategic and academic overview of

population health improvement. It

describes how Force Health Protection, worksite and community-based

programs, and TRICARE health plan

programs are integrated in DoD. It

also provides a primer on population

health that includes definitions and

discussions of how to measure

population health, the determinants

of health, and primary, secondary and

tertiary prevention strategies.
vi

Force Health Protection (FHP) is

the doctrine that describes how

DoD will protect the health of

fighting forces. Section II introduces the FHP doctrine and the

pillars—healthy and fit force,

casualty prevention, and casualty

care and management.

The Military Health System can

have a significant positive effect on

population health through worksite

and community-based programs.

The scope of interventions that can

be implemented in worksite and

community-based venues is very

broad. Worksite and communitybased programs for population

health improvement (Section III)

should address areas of health

promotion and protection (including environmental health), disease

and injury prevention and screening, and public health surveillance.

The Military Treatment Facility

(MTF) Implementation Guide,

Section IV, describes the strategy

and seven key process elements that

will drive the MHS implementation

of population health improvement

activities through the TRICARE

health plan. The key process

elements are:

1. Identify the population

2. Forecast demand

3. Manage demand

4. Manage capacity

5. Evidence-based primary,

 secondary & tertiary prevention

6. Community outreach

7. Analyze performance and

 health status

A detailed discussion of the

concepts, functions, roles, and tools

is presented for each process

element. Also, links are included to

program offices, reference materials and tools so that readers can

develop and implement process

elements.

This PHI Plan creates functions

and structure that will enable the

MHS to implement population

health improvement programs

across the MHS. Regional Lead

Agent population health offices

(Section V) will facilitate communication between MTFs, Managed

Care Support Contractors and

enterprise-level planners, policymakers and programmers. The

MHS will operate as a learning

organization supported by the MHS

Optimization and Population

Health Support Center (OPHSC)

(Section VI) that merges concepts

of evidence-based decision-making

with lessons learned and disseminates them across the system.

Education and assimilation of

these principles throughout the

MHS is compulsory. The strength

of the MHS is its control over the

military clinicians’ educational

process from undergraduate to

professional, and from basic

military education through

technical training. In particular,

clinic level personnel must have the

skill to use the tools described in

this document. This will require a

concerted effort across the MHS.
1

Population Health

Improvement

Plan and Guide

Introduction

The Military Health System (MHS) is

a large and unique integrated health

system. Like all health systems, the

MHS must continually improve

health services while effectively

managing limited resources. To this

end, the MHS Optimization Plan

(http://www.tricare.osd.mil/

mhsoptplan/optim/

MHSOT_optim.html) was drafted to

outline the key tasks that, if coordinated and integrated, will improve

the quality and cost-effectiveness of

services provided by the MHS. A

cornerstone of the Optimization Plan

is its focus on population health.

The population health imperative is

to develop and implement a plan

and model to “optimize clinical

outcomes across the MHS” and

improve health by shifting from an

emphasis on disease and injury

intervention to prevention and health

promotion. The targets for population health initiatives include all

members of the military community;

Active Duty, Guard and Reserve

Forces and their families, and

military retirees and their families.

This plan and guide provides the

conceptual framework for improving

the health of populations and will

guide users to specific actions and

tools that will help to build healthy

communities. It also provides

guidance in support of a uniform

health care system based on systematic clinical and business decision

processes. The PHI Plan and Guide

is not intended to include every detail

required for successful implementation. Rather it is intended to provide

guiding principles, key processes,

tools and resources that can be used

in developing the population health

improvement strategies and programs necessary for successful

Service and MTF implementation.

Population Health Improvement and the Military Health

System (MHS) Optimization Plan
2

Boxes like this one are used throughout the Plan to elucidate how the many

principles and processes presented can be applied to an important health issue.

Smoking rates among military personnel continue to be high

compared to the overall population. Smoking is the leading cause

of preventable mortality in the United States. Given the huge

burden of smoking-related morbidity and mortality, it is reasonable to assume that smoking is a major factor in many of the

health problems that will be addressed by MHS programs. Therefore, smoking is an appropriate issue to use for demonstrating the application of

principles and processes of population health improvement presented in this

document.

The picture that accompanies the examples for smoking as a population health problem is

from the painting titled Skull and Burning Cigarette. Vincent van Gogh painted the picture in

1885, roughly eighty years before release of the first U.S. Surgeon General’s report on smoking.

How to Use This Plan & Guide

The Population Health Improvement

(PHI) Plan and Guide will be useful to

each user in a unique way. The following

descriptions of the sections in the Plan

will help readers easily identify those

sections that they want to use now and

those sections they may use at another

time. For example, personnel involved in

traditional clinical care may immediately

benefit by first reading Section IV and

reading Section I after they have assimilated the content in Section IV. Leaders

and staff responsible for plans, programs

and resources at Headquarters, Service

intermediate commands, Regional Lead

Agent offices, and Military Treatment

Facilities (MTFs) will benefit from the

strategic concepts and tactical principles

presented in Section I. All readers will

enjoy the text boxes that use smoking as

a major health issue to exemplify the

principles and processes presented.
3

Summary of the Sections

Section I.

Overview of Population

Health Improvement

The overview provides a conceptual

framework for population health

improvement from planning through

performance monitoring and

improvement. This framework

incorporates the processes used by

well managed and forward thinking

health plans and of public health

programs. Population heath and

population health improvement are

defined and a discussion of those

factors, or determinants, that impact

health is presented. The overview

provides an academic and a strategic

discussion of population health

improvement in the Military Health

System and introduces four principles

for improving the health of military

communities:

1. Define the populations targeted

 for interventions

2. Use applied epidemiology

3. Use evidence-based clinical and

 business interventions, and

4. Manage information to support

 ongoing health status

 assessment, planning, and

 performance monitoring and

 improvement

The following sections provide readers

a more detailed “how to” guide for

tasks for population health improvement.

Section II.

Force Health Protection

Population health improvement

activities will directly support the

military mission. Force Health

Protection doctrine describes these

activities in three parts, or pillars;

healthy and fit force, casualty

prevention and casualty care and

management. Whether targeting

troops “in garrison” or forces in

operational and deployed status,

population health improvement

principles can be applied. Section II

provides an introduction to the three

pillars of Force Health Protection in

the context of population health

improvement.

Section III.

Worksite and CommunityBased Programs

Worksite and community-based

programs include many activities that

occur outside traditional health care

settings. They can be ideal settings

for a number of health-impacting

initiatives. This section outlines

worksite and community-based

programs that should be included in

MHS population health improvement

strategies. Resources for existing

programs in the three Services are

identified as well.
4

Text Boxes

Text boxes are used throughout

the Plan to provide examples that

further explain principles and

processes and to present information that augments the main

Section IV.

Health Plan: Military Treatment Facility Implementation Guide

The Military Health System’s greatest

impact on the health of populations

will result from a shift in emphasis

from interventional (individual) to

preventive (population-based)

services in MTFs, combined with

worksite and community-based

prevention and wellness programs.

This section provides definitions and

detailed discussions of the seven key

process elements of population health

improvement that have been identified for implementation throughout

the MHS. The seven key process

elements are:

1. Identify the population

2. Forecast demand

3. Manage demand

4. Manage capacity

5. Evidence-based primary,

 secondary & tertiary prevention

6. Community outreach

7. Analyze performance and

 health status

Military Treatment Facilities are

targeted in Section IV as leverage

points for making this critical shift in

emphasis through implementation of

population-based processes for

delivering the TRICARE benefit and

other services. Section IV also

includes examples of tools and

programs that support population

health improvement activities at the

MTF.

Section V.

Regional Lead Agent Population Health Offices

Regional Lead Agent offices provide

support through geographic alignment of MTFs and can directly

support MTFs in population health

initiatives. This section provides a

framework for the evolving role of

these offices to support population

health improvement and outlines the

functions and infrastructure needed

to support MTFs and Managed Care

Support Contractors and collaborate

on MHS population health initiatives.

Section VI.

MHS Optimization and

Population Health Support

Center (OPHSC)

This section describes the functions

and structure of the MHS OPHSC that

is being developed to support

Regional Lead Agent, Service

Headquarters, Service intermediate

command, and MTF population

health offices and clinic teams. Until

the MHS OPHSC is fully operational,

questions and comments about the

principles, processes, tools and

resources in the PHI Plan and Guide

can be communicated to the contacts

at http://www.tricare.osd.mil/opt_int/

PHIT_Member.htm.

Section VII.

Tables of Population Health

Functions and Tools

Tables are provided to serve as a quick

reference to the functions associated

with the key process elements of

population health improvement, to

tools that support each process

element, and to points of contact for

further information.

Guidance for Accessing

Internet Sites and Other

Resources

There are numerous Internet links

and resource offices referenced

throughout this document. Every

effort will be made to ensure the

current Internet addresses and

resource contacts are provided. If an

Internet site is not opened by clicking

on the link in the text, copy the

address and paste it into the address

window of your Internet browser.

Please call the MHS Optimization and

Population Health Support Office at

(703) 681-3637 (DSN 761) if any of

the offices, Internet sites or references

cannot be contacted with the information that has been provided.
5

A Conceptual Framework for

Population Health Improvement

Combining Military-Unique

Programs, Public Health Functions and Health Plan Best

Practices

The Department of Defense (DoD) has

responsibility for a comprehensive

portfolio of health programs to support

the national defense strategy and to

improve the health of military communities. These programs are very diverse,

ranging from traditional health care

services provided in hospitals and clinics

to environmental health and disease

surveillance in remote locations. Health

protection, health promotion, treatment

and rehabilitative services, and assessing

and monitoring health status are all DoD

responsibilities.

The programs within the DoD can be

considered using a number of different

organizational structures. For example,

programs can be grouped as those

directed by the Army, Navy, or Air Force. A

more useful structure for considering

programs as they impact population

health categorizes programs into three

areas; military-unique programs

(Force Health Protection),

programs that are worksite or

community-based (Worksite and

Community-Based Programs),

and traditional health insurance

and managed health plan programs

(Health Plan: TRICARE Benefit). This

structure is depicted in Figure 1.

Force Health Protection (FHP)

programs include those health services

activities that are intended to explicitly

enhance military operations. They are

targeted primarily at Active Duty, Guard,

and Reserve service members. Force

Health Protection is a Joint Force strategy

that moves beyond traditional medical

support for contingency operations to a

new doctrine that emphasizes fitness,

health promotion and wellness, and the

prevention of casualties (http://

www.dtic.mil/jcs/j4/divisions/mrd/).

Force Health Protection integrates three

pillars: a fit and healthy force, casualty

prevention, and casualty care and

management. While the concepts in the

three pillars are not new, current military

medical doctrine now clearly articulates

how all three must be in place and

operating effectively during peacetime

and in operational contingencies to fully

support deployed fighting forces.

Worksite and community-based

programs programs programs include the many functions

and services that are provided outside of

traditional health care settings. Worksite

programs may be in an industrial setting

such as a shipyard, in an office, or in a

unique setting such as a military training

center. Occupational health services and

health promotion activities at worksites

can be among the most effective programs available for impacting individual

and community health. Many community-based programs have typically been

considered to be the responsibility of

public health agencies and specialized

service organizations. The core functions

and essential services of public health

effectively capture the scope of DoD

activities for population health improvement (see Textbox). The core functions

are health assessment, policy development, and assuring that health services

are provided (IOM 1988; Public Health

Functions Steering Committee 1995).

Examples of worksite and communitySection I.

Overview of

Population Health

Improvement

Figure 1. Three areas of DoD
6

based programs within the DoD include

base safety and health committees,

environmental and occupational health,

family support services, worksite wellness

programs, Health and Wellness Centers

(HAWCs), fitness centers, health-related

education programs, and the Women,

Infants and Children (WIC) program for

overseas families. These and other

worksite and community-based programs

play a critical role in improving health in

military communities.

Worksite and community-based programs can directly and indirectly impact

the health of military communities.

Some programs that focus on the nonmedical determinants of health can

greatly contribute to community health

improvement but are not under the direct

jurisdiction of military health programs.

Health authorities commonly provide

advice or collaborate on such programs.

The military health plan, as defined by

TRICARE, includes programs that are

targeted to active and retired military

service members and their families.

Health care services under TRICARE are

provided through either the arrangement

of care provided by civilian providers or

delivery of services directly in military

treatment facilities. Arranging and

directly providing health care services are

functions analogous to those of commercial health plans. Military Health System

programs that are defined by the

TRICARE health plan are directly

comparable to programs managed by

commercial indemnity and managed

care health plans.

Health care services are defined by the

benefit package to which individuals or

groups have contractually agreed. The

federal government, like large commercial health plans, both manages the

financial risk for the benefit and serves as

the primary provider for services for the

military beneficiary population. Furthermore, the DoD is a major purchaser of

health services through Managed Care

Support Contracts and through the

indemnity plan, TRICARE Standard.

The three

areas of

health

programs and

the services

and functions

within them

clearly overlap

and interact.

For example,

in executing

traditional

health services

such as acute

and chronic

disease care

under the

TRICARE

health plan,

some of the requirements for maintaining a fit and healthy force are met.

Worksite programs that improve the work

environment and health of troops also

support force health protection and

manage demand placed on the health

plan. The MHS, in coordination with

military departments, must establish the

plans, policies, and programs necessary

to achieve the mission and must execute

programs effectively or assure that health

programs are executed by other responsible agencies.

While the MHS is mandated to support

military operations and provide or assure

health services defined by the TRICARE

health plan, it must do so in an environment with increasingly constrained

resources. The MHS can meet the

challenge to improve value in all services

and improve the health of military

communities by adopting and adapting

the best practices of both public health

agencies and model health plans.

The scope of the MHS is broad when

conceptualized as a combination of

functions core to public health agencies

and functions carried out by large health

plans today. Add to this the execution of

these functions in military-unique

environments and a picture unfolds of a

health system with a scope and reach that

is unparalleled in the world. To put these

functions into operation requires an

understanding of the factors that impact

health, the systematic planning required

to prioritize programs, and the concepts

and processes of population health

improvement at the MTF, Region, and

DoD levels.

Core Functions and Essential Services of Public Health

(Public Health Functions Steering Committee 1995)

Assessment includes activities necessary for community health diagnosis. Surveillance,

identifying and analyzing problems, collecting and analyzing data, and evaluation of

outcomes are some activities of assessment. Through assessment the MHS understands

community health needs. Policy development is the function that connects ways and

means for solving health problems. It includes processes for making decisions, setting

goals, and allocating resources. Assurance is the critical public function to make sure

things that should be done get done, doing the right things, and that they are done

correctly; that is, doing things right. It makes sure necessary services are provided to reach

goals and includes directly providing services if necessary.
7

Health Continuum

 Wellness Illness

Figure 2. Figure 2. Figure 2.

The health continuum

Defining and Measuring the

Health of Populations

What is Health?

The World Health Organization defines

health as “a state of complete physical,

mental, and social well-being and not

merely the absence of disease or infirmity” (WHO 2001). This is perhaps the

broadest context for defining the health of

individuals or groups of people in a

community. Health may be viewed

differently from various perspectives. For

example, having healthy military troops

might mean that personnel are in

maximum physical and mental condition to achieve peak performance and to

prevent illness and injury. Children’s

health may be considered differently.

Healthy children are not only physically

and mentally well but also are growing,

learning, and thriving socially.

Health among individuals varies greatly

and represents a continuum from one

extreme of wellness to the other of illness

or impairment. Health can be qualitatively and quantitatively measured and

the result is often referred to as health

status. There are many measures for

individual health status such as presence

or absence of disability, quality of life,

and presence or absence of specific

diseases or risk

factors.

Population

health is “the

aggregate health

outcome of

health adjusted

life expectancy

(quantity and quality) of a group of

individuals, in an economic framework

that balances the relative marginal return

from the multiple determinants of

health” (Kindig 1997). It is also

commonplace to describe the health

status of the community at large, or

population. Life expectancy, for example,

is a global measure of the cumulative

effect of many factors on a population’s

health and is a type of survival analysis

done only at the population level.

Similarly, mortality rates are a global

measure of the risk of dying in a population. Community level measures of

quality of life or functional status

represent the “average” of these measures

taken for individuals in the community.

The proportion of individuals in the

population that have a certain disease or

risk factor at a given time yields a

prevalence rate for a disease, injury, or

risk factor. Other global measures of

health include Quality Adjusted Life Years

(QALYs), Years of Potential Life Lost

(YPLLs), and Disability Adjusted Life

Years (DALYs). Any of these measures

alone or in combination may be used to

describe the health of populations.

Population health improvement Population health improvement is

the balancing of awareness, education,

prevention and intervention activities

required to improve the health of a

specified population. This model unites

self-care, MTF, worksite and communitybased prevention and wellness activities,

and medical interventions into a

comprehensive paradigm centered on

primary, secondary, and tertiary prevention to reduce morbidity and premature

mortality and improve health. The

objective of population health improvement is to achieve measurable gains in

the health of a defined population over

some defined period of time. Because

community health status can be periodically measured and new knowledge

brings improved services and programs,

initiatives to build healthy communities

will be ongoing. To achieve population

health improvement objectives, a

systematic approach must be employed at

all levels of the MHS to establish,

implement and improve populationbased plans and programs.

Measuring the Health of Populations

Assessing, or measuring, the health status

of populations to support the development of policies and programs in the

MHS must be ongoing, comparable

among various populations, and must

measure effects of the interventions over

the interval between assessments. The

periodic use of population-based

measures must demonstrate not only

current health status but also trends and

progress made on priority health issues

(HHS 1993). Health data from military

communities should be comparable

among military communities and to

other communities to facilitate

benchmarking

and so that

data can be

aggregated

at Regional

levels.

While counting health events (e.g.,

illnesses and injuries) is a common

activity in medical and public health

practice, the systematic use of health data
8

Determinants of Health

To improve the health of individuals and

of whole communities, one must start

with an understanding of the factors that

impact on both individual and community health. These factors are commonly

referred to as determinants of health

(Figure 3). Healthy People 2010 (http://

www.health.gov/healthypeople/), the

national initiative for health promotion

and disease prevention, presents an

overview of how individuals’ behaviors,

biology, and physical and social environments interact to positively and negatively

impact health (HHS 2000). Healthy

People 2010 also describes how policies,

programs and access to quality health

care directly and indirectly influence the

health status of individuals and communities.

An individual’s biology is a result of their

genetic makeup and the cumulative effect

of exposures and other events that can

cause permanent or temporary alterations in health. Some biological

attributes positively impact health while

others have negative impacts. For

example, specific genes in women confer

increased risk for breast cancer while

other genetic factors contribute to a lower

risk for coronary artery disease.

Behaviors and conditions in the physical

and social environment can also affect

health. Some behaviors, such as a

physically active lifestyle, have positive

health effects. Other behaviors, such as

smoking, have negative effects. Exposure

to polluted air, high noise levels without

hearing protection and extreme environmental conditions (e.g., hot, cold or dry

conditions) without proper protection are

examples of factors in the physical

environment that can adversely impact

the health of individuals.

The presence of family, a strong social

network, or religious association are

examples of healthy factors in one’s

social environment. Associating with a

group of friends that binge drink alcohol

is an example of an unhealthy factor in

to improve community health requires

measuring lifestyle and behavioral risk

factors and the burden of chronic diseases

in populations. The identification,

investigation and analysis of risk factors

require population-based measures.

Population-based measures are rates of

events in a population. A rate is calculated by dividing the number of events

over a specific period of time by the

population of interest (e.g., persons at

risk for that event). Population health

rates, then, use health events in the

numerator and the population of interest

in the denominator. For a given measure, the time period for counting events

and for measuring the population should

be the same e.g., one calendar year (Tyler

and Dicker 1997). An important

requirement of population health

measures used to support data-driven

population health decisions is to clearly

define the numerator and denominator of

each measure.

For population health measures to

support surveillance and performance

measurement they should be measured

periodically over time and comparable

among measurement periods to support

trend analysis (HHS 2000). The frequency at which each measure is

collected should be determined by the

interval over which meaningful change

can be expected and be linked to long,

intermediate, and near-term objectives for

health programs (see Using Objectives

for Improving Health Status and for

Monitoring Performance).

Figure 3. Figure 3. Figure 3.

Determinants of health (HHS 2000) Determinants of health (HHS 2000)
9

one’s social environment. The key point

is that all these determinants interact to

influence the health of individuals and

communities.

The presence or absence of factors that

can impact health can be assessed in

individuals, at worksites, and in military

communities. Policies and interventions can be targeted to specific populations to mitigate factors that increase the

risk for disease or injury. Policies

requiring immunization of children prior

to entry into school and legislation to

reduce driving under the influence of

alcohol are two examples.

Specific policies and interventions can

also be developed to increase the prevalence of factors that improve health or

decrease the risk for disease or injury. For

example, community programs to

discourage binge drinking of alcohol can

be targeted to those groups where such

behavior is most prevalent. Also, a

meningococcal vaccine program might

target military units that are deploying to

a location where the risk for the vaccinepreventable disease is high.

Access to quality health care is of

paramount importance to ensure that all

persons receive effective health services

when and where it is needed. For

example, children must have access to

care to receive appropriate immunizations and failure to receive apprropriate

immunizations places entire communities at increased risk for disease.

It is important to consider the relative

importance of various determinants of

health in MHS population health

improvement initiatives. The graphs in

Figure 4 show that the leading diseasespecific causes of death in the United

States have behavioral, lifestyle and

environmental actual causes of death

(the direct contributing factors that lead

Leading Causes of Death, United States, 

1990

0% 10% 20% 30% 40%

HIV

C hronic Liver

S uicide

D iabetes

P neumonia/Influenza

COPD

Injuries

C erebrovascular

C ancer

Heart Disease

Cause of Death

Percent of All Deaths

Actual Causes of Death, United States, 1990

0% 5% 10% 15% 20%

Illic it Drug Use

Mot or Vehicles

S exual B ehav ior

F irearms

Toxic Agent s

Microbial Agent s

Alcohol

Diet /Inac t iv it y

T obacc o

Factor Contributing to Deaths

Percent of All Deaths

Figure 4. Figure 4. Figure 4.

Comparing leading and actual causes of death (McGinnis and Foege 1993) Comparing leading and actual causes of death (McGinnis and Foege 1993)

to the diseases that cause deaths). The

ten leading causes of death represent the

pathophysiological conditions present at

the time of death rather than the internal

and external factors that were the causes

of the pathophysiological conditions. The

actual causes of death show that most of

the burden of chronic and acute disease

and injury is the consequence of identifiable risk factors. Many of the risk factors

can be attributed to health risking

behaviors and preventable infections and

injuries. While treating the pathophysiological conditions in individuals is of

great importance in population health,

decreasing risk for disease by mitigating

risky behaviors and protecting communities from infectious and toxic agents will

contribute even more to population

health by preventing disease, injury and

disability and improving both quality of

life and longevity.
10

Primary, Secondary, and Tertiary

Prevention Strategies

The health continuum can be used to

conceptualize the potential for individuals’ health status to progress from good

health to at-risk for disease or injury to

diseased or injured to impaired. It is

possible for individual health status to

move toward health as well. This

conceptual progression illustrates three

intervention points to target strategies to

prevent individuals from moving toward

illness and move some toward wellness.

The three intervention points are when

individuals are well or have identified

risk factors for diseases or injuries; when

individuals have early, asymptomatic

diseases or injuries; and when individuals

have symptomatic diseases or injuries.

The three strategies that can target these

points are referred to as primary

prevention, secondary prevention, and

tertiary prevention (Turnock 1997).

Figure 5 illustrates the relationship

between the health continuum, intervention points and prevention strategies.

Primary prevention is the strategy to

prevent disease or injury through two

approaches; reducing risk factor levels

and reducing exposure to potentially

harmful agents or conditions. Health

promotion is the term used to describe

those activities that reduce risk factor

levels by modifying behaviors that can

affect exposure to harmful agents or

conditions. Examples of health promotion activities in the clinical setting at an

MTF include diet and exercise counseling

and health education. Health promotion

activities at worksites or in the community may include policies that promote

physical activity or provision of recreational facilities, and housing and

building standards. Health protection

activities attempt to decrease the likelihood for harmful interactions between

individuals and toxic factors and to

increase resistance to potentially harmful

factors. Environmental policies, industrial hygiene programs, and immunizations are examples of activities that

protect groups from harmful effects of

toxic or virulent agents (Turnock 1997).

Secondary prevention refers to early

detection and prompt treatment of

diseases or injuries when they are at an

early, typically asymptomatic, stage.

By detecting diseases and injuries early,

secondary prevention may return

individuals to a state of health, or

significantly limit the damage to

individuals’ health, and prevent recurrence. Community-based, worksite and

clinic-based screening programs are

examples of secondary prevention

activities. The MHS is putting a high

priority on integrating secondary

prevention into routine clinical activities.

A program to detect latent tuberculosis

infection (positive PPD) in high-risk

individuals is an example of case finding

as a secondary prevention activity

(Turnock 1997).

Figure 5. Figure 5. Figure 5.

The relationship between the health continuum, intervention points, and The relationship between the health continuum, intervention points, and

primary primary, secondary , secondary, and tertiary prevention strategies , and tertiary prevention strategies

Health Promotion

& Protection

(Primary

Prevention)

Early Detection &

Case Finding

(Secondary

Prevention)

Treatment and

Rehabilitation

(Tertiary

Prevention)

Health Risk Disease Impairment

Health Continuum

 Wellness Illness

Tertiary prevention includes familiar

clinical activities such as treatment of

symptomatic acute and chronic

diseases and injuries to limit further

damage to health and restore function

(Turnock 1997). It includes rehabilitation

where damage has already occurred.

Increasingly, individual case and

condition/disease management programs

are used to achieve increased effectiveness

and efficiency from tertiary prevention

services.

Within the DoD programs for Force

Health Protection, worksite and community-based population health, MTFs and

TRICARE health plan, prevention

strategies must be employed in a balance

that optimizes population health. Force

Health Protection is not only about

casualty care, a tertiary prevention

strategy, but puts renewed emphasis on

primary and secondary prevention

strategies to prevent disease and injury

and improve health. For example, Force

Health Protection is about ensuring that

troops are protected from hazards such as

vaccine-preventable infections and are in

top physical and mental condition to

remain resilient to injury and illness.
11

Lung Cancer Mortality, United States, 1950-95

0

10

20

30

40

50

60

70

80

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995

Year

Age-adjusted yearly death rate per 100,000 

population

Male

Female

Total

Smoking Rates, Adults, United States, selected 

years, 1965-98

0

10

20

30

40

50

60

1965 1970 1975 1980 1985 1990 1995

Year

Percent of persons

Male

Female

Total

Figure 6. Figure 6. Figure 6.

 Lung cancer mortality (CDC 1993; NCI 2001) Lung cancer mortality (CDC 1993; NCI 2001)

 and smoking trends (NCHS 2000) and smoking trends (NCHS 2000)

Worksite and community-based programs emphasize health promotion and

protection and can also present good

venues for secondary prevention activities.

Finally, though the current TRICARE

health plan is directed mostly at diagnosis and treatment of established diseases

and injuries, coverage is increasing for

primary and secondary prevention

services. Military Health System programs are putting more emphasis than

ever before on ensuring that MTF and

contract providers improve delivery of

recommended preventive services to

promote wellness, prevent disease and

injury, and thereby extract the best value

from clinical capacity.

The imperative to maximize primary

prevention wherever possible is exemplified by the burden of illness from lung

cancer. Cancer is the second leading

cause of death in the United States and

carcinoma of the lung is the number one

cause of cancer deaths for both women

and men. The overall death rate from

lung cancer peaked around 1990 and has

declined slightly since (Figure 6)

(Fielding, Husten and Eriksen 1998).

This success, however, is not due to

progress in secondary or tertiary prevention. In fact, the 5-year survival rate for

lung cancer has remained at less than

13% for many years, and there is not an

effective method of screening for lung

cancer (U.S. Preventive Services Task

Force 1996). Smoking is the leading

preventable cause of deaths overall,

including deaths from lung cancer.

Eighty-three percent of lung cancer

deaths are attributable to smoking

(Fielding, Husten and Eriksen 1998).

Environmental tobacco smoke has been

proven to cause lung cancer in nonsmokers as well. Health promotion and

protection activities to prevent smoking

initiation, assist smokers to quit, and to

protect non-smokers from tobacco smoke

have been credited with the recent decline

in lung cancer death rates in men (CDC

1999).

The story for lung cancer is an example

of the potential of primary prevention

strategies to impact a leading cause of

premature morbidity and mortality.

Using a systematic approach based on

knowledge of the health status and

distribution of determinants of health in

populations will ensure that DoD

organizations develop and execute

effective policies and interventions to

improve the health of military communities.
12

Making Population Health

Improvement a Reality in

Department of Defense

A Systematic Approach

A systematic approach to population

health improvement implies that

activities are derived from organizational

goals and objectives, use populationbased health methods to plan, resource

and implement policies and programs

(including health care services), and

achieve measurable gains in the health

status of military communities.

Starting at the highest levels of the

organization and cascading to the local

level, activities must be aligned with the

Department’s mission, vision and goals.

The mission is what the organization is

currently doing. The vision is where it

wants to be in 5-10 years. The goals can

be used to develop a strategic plan for

how the vision will be reached. Within

the strategic plan are short-, intermediate-, and long-term goals that are

measured quantitatively with specific

objectives. In population health, the

vision is healthy people, healthy

worksites, and healthy communities. The

local strategic plan should describe how

to reach goals and objectives that reflect

the best possible health status for

individuals, worksites, and military

communities.

The DoD enterprise, TRICARE Regions,

Services, and MTFs should all employ a

systematic and evidence-based approach

for developing health plans, policies and

programs. Integrated approaches that

combine the best evidence-based disease

and injury prevention and intervention

paradigms will be the most successful.

Planning and prioritization should be

driven by population health data and by

other priorities set forth by leadership.

The planning process and resultant

policies and programs should reflect the

application of population-based epidemiologic methods. Also, organizations

should align the measurement of

program performance with pre-established objectives for population health

improvement. This requires an overall

information management strategy that

links the plans and priorities to operational activities. A gap analysis should be

completed to identify changes needed to

implement population health improvement plans. Finally, plans and programs

should drive resource requirements so

that the right capacity and capability of

personnel and appropriate space,

funding, and materiel are employed to

achieve population health improvement

objectives.

Plans, Policies, and Programs

At any given time, the responsibilities of

the MHS are being met through established programs that address previously

identified and prioritized problems.

However, the health of a population and

the political and scientific bases for

health service activities are very dynamic.

New health issues continue to emerge,

new interventions are found for problems

already targeted by established programs,

and new information about the distribution and determinants of health problems

in the population suggest the need for

new priorities or other approaches.

Therefore, each organization must have

ongoing mechanisms for health planning

and programming that capture the

dynamic nature of population health

improvement. An analysis of the

performance in core public health

functions by over 2800 local health

departments in the United States showed

that departments that used a formal

Military Health System Mission, Vision, and Goals

MISSION

The Military Health System (MHS) mission is to support the Department of Defense

(DoD) and our nation’s security by providing health services for the full range of

military deployments and by sustaining the health of members of the armed forces,

their families and others.

VISION

The MHS is responsive and accountable to DoD, line leadership, and our beneficiaries

to ensure force health protection and optimize the health of MHS beneficiaries by

providing best value health services using best clinical and business practices.

GOALS

· Protect our forces from medical threats anywhere in the world under any circumstances.

· Employ a comprehensive health plan for those entrusted to DoD’s care.

· Create healthy communities through the use of health promotion and prevention

activities.

· Fully optimize clinical outcomes across the MHS.
13

planning process had higher performance scores for the eight public health

functions analyzed (Suen, Cooper and

Taylor 1995). Agencies using a formal

planning tool had the best performance

scores for health-related data collection,

surveillance, and outcome monitoring

and for investigation and control of

diseases and injuries.

Several community-based models have

been developed to help with community

health assessments and planning. Three

examples of such planning models are

found in the following tools (see references for links to these):

 Assessment Protocol for Excellence in

Public Health (APEX/PH) (NACCHO

1991)

 Planned Approach to Community

Health (PATCH) (HHS 1993)

 Healthy Communities 2000: Model

Standards (APHA 1991)

All three planning tools have similar

models for integrating health assessment

and surveillance in community health

planning. In developing and monitoring

a community health plan, health

problems are identified and analyzed

based on epidemiologic methods that link

health problems to possible interventions.

The organization should have data to

describe the burden and distribution of

health problems in the population. The

overall burden of health problems in the

community can serve as a starting point

for prioritizing and analyzing health

problems. Health problems are then

prioritized to dictate policies and

programs based on available resources.

These and other formal health planning

tools can prove helpful to MTFs and other

organizations when conducting regular

and periodic health planning.

To improve the health of military

communities, the DoD must continuously

plan and develop policies and programs

using a cyclical approach. The cycle

includes all these steps; assessing the

health status of beneficiaries, identifying

risk factors for disease and injuries under

the framework of determinants of health,

prioritizing health problems, developing

and implementing programs, and then

reassessing the health status of beneficiary populations.

Principles Guiding Population

Health Plans, Policies, Programs

In all DoD activities—those in Force

Health Protection, worksite and community-based programs, and TRICARE—

plans, policies, and programs will be

most effective at improving population

health if four population health principles are employed. The principles are:

 Define the populations targeted for

interventions,

 Use applied epidemiology,

 Use evidence-based clinical and

business interventions, and

 Manage information to support

ongoing health status assessment,

planning, and performance monitoring and improvement.

Defined Populations

The first step in developing health

policies, programs and interventions is to

define the population that is at-risk for

health altering events, such as diseases or

injuries. There are innumerable ways to

define populations but a practical starting

point is to use the health assessment that

identified the problems in the community. For example, if back injuries have

been identified as a priority problem

among active duty troops on base then

the population could be defined by the

base active duty population. Larger

populations might be considered when

planning health services under the

TRICARE health plan. The population

might be identified as those beneficiaries

living in the catchment area for purposes

of planning services and resources to

provide care in the MTF and through

contract services in the local community.

Smoking rates among military personnel have been higher than the overall US rates

for the past 20 years. The overall smoking rate among Active Duty military personnel in 1998 was 30 percent, well above the national rate of 24

percent. Smoking is the leading preventable cause of premature

mortality in the United States. It causes morbidity and mortality

from cardiovascular, cerebrovascular and respiratory disease,

cancers and other diseases. Given the high smoking rates among

military personnel and the huge burden of smoking-related

morbidity and mortality throughout the US population, it is not surprising that

smoking is a major risk factor for many of the health problems and chronic diseases

treated by military providers. Therefore, smoking may exemplify a high priority

health problem to target in MHS programs. Similarly, smoking rates and other

measures of the results of programs targeting smoking can be periodically assessed.

Smoking as a health problem and smoking prevention and cessation as interventions are realistic and tangible examples for presenting the principles and processes

of population health improvement.
14

A specialized diagnostic or therapeutic

service provided by a Center of Excellence

might define the population as those

living within the TRICARE Region, or

even the entire MHS beneficiary population.

A deployable Army unit or the crew on a

ship may be the population for a Force

Health Protection activity such as an

immunization program for troops likely

to go to the Middle East. For MTF

activities to implement the TRICARE

health plan, the MTF enrolled population

can be used to define the population for

planning MTF-specific policies and

programs. Defining the populations

assigned to individual Primary Care

Managers (PCMs) i.e., the patient panel,

is perhaps the most useful way to identify

groups of beneficiaries that are small

enough to target patient-specific primary,

secondary and tertiary prevention

interventions. Worksite and communitybased planning for policies, programs,

and interventions may want to include all

TRICARE beneficiary groups (TRICARE

enrollees as well as those not enrolled) in

defining populations at risk for acute or

chronic diseases and injuries and lifestyle

or behavioral risk factors.

Applied Epidemiology

Epidemiologic methods are used to

describe the distribution and determinants of disease and injury in the

population and of the risk factors and

underlying causes of diseases and

injuries. They also help in identifying

possible interventions to resolve problems.

Health information used at all levels for

population health improvement must

accurately represent the distribution of

morbidity and mortality in the community and their causes. Surveillance of a

wide array of health data sources is

necessary for the identification of health

events or trends that may warrant action.

The population health information must

be acquired and applied based on the

science of epidemiology (Tyler and Dicker

1997).

The following terms are important in

using principles of applied epidemiology

in planning population health policies

and programs:

 Health problems are any health

issues that the community defines as

problems. Health problems are

typically undesirable conditions such

as death, disease, or disability

(NACCHO 1991). Epidemiologic

methods for identifying and investigating adverse health events can

support data-driven problem

definition. For example, diseasespecific death rates in a subpopulation of the community or

injury rates within a geographic area

may be used to describe problems for

action.

 Risk factors are “Scientifically

established factors (determinants)

that relate directly to the level of a

health problem” (NACCHO 1991).

There may be numerous risk factors

for a given health problem and,

conversely, any given risk factor may

contribute to numerous health

problems.

 Direct and indirect contributing

factors. Factors that have been

scientifically established to directly

affect the level of a risk factor are

direct contributing factors. Those

community-specific factors that

affect direct contributing factors are

indirect contributing factors

(NACCHO 1991).

Epidemiology is applied in population

health programs through four tasks:

surveillance, investigation, analysis, and

evaluation. Surveillance is the ongoing

collection and analysis of health data for

the support of health planning, programming and evaluation. Monitoring the

overall health status of the population or

sub-populations to identify possible

health problems is part of surveillance.

Epidemiologic investigations study

health problems to identify characteristics

of health events and risk factors or

contributing factors. Analysis is the

formal task of taking data about health

problems and converting it to information that will lead to interventions.

Investigation and analysis identify risk

factors and direct and indirect contributing factors of health problems. Evaluation is the assessment of health policies

and programs against their intended

objectives in addressing problems.

The epidemiologic tasks of surveillance,

investigation and analysis are used in

health planning and all depend heavily

on population-based health data. The

tasks result in a series of hypotheses about

a health problem. These hypotheses

eventually lead to interventions for

addressing the problem. Figure 7 shows

how a health problem identified through

ongoing surveillance can be investigated

to identify risk factors and then analyzed

for direct and indirect contributing

factors. The analysis continues with the

identification of interventions for possible

implementation.

The applied epidemiology process can

directly support the need to manage

services provided under the TRICARE

health plan. The need to effectively
15

match health services capacity with

demand for services requires a process to

forecast demand. Through the application of epidemiologic methods, information about known health status or

projected health problems in populations

can be used to project the timing, scope,

and quantity of each type of service or

intervention that will be requested or

needed by the target population. This

should include proactive identification

and delivery of all recommended clinical

preventive services. Also, this approach is

used to determine the need, or demand,

for Force Health Protection, worksite,

community-based, and MTF programs.

Evidence-based Interventions

There is a growing demand in public

health and medical practice to use

explicit evidence-based information to

improve the effectiveness of health

services in achieving population health

improvement objectives. Evidence-based

medicine is a term used to describe the

use of practices and interventions that

have been derived from explicit scientific

methods for proving effectiveness.

Evidence-based principles that include

systematic reviews of scientific evidence

have been used in developing prevention

guidelines beginning with the early work

done by the Canadian Task Force on the

Periodic Health Examination and the

U.S. Preventive Services Task Force

(Wallace 1998). The terms evidencebased medicine (EBM) and evidencebased health care (EBHC) are sometimes

used to describe evidence-based principles

and practices applied in direct patient

care (EBM) and in worksites, communities, and populations (EBHC).

Evidence-based practices, as they apply to

MHS population health improvement and

optimization, can be considered in two

categories: 1) evidence-based primary,

secondary, and tertiary prevention,

and 2) “evidence-based” business

practice. By using evidence-based

prevention strategies the MHS will ensure

that all health programs targeting

individuals and populations are “doing

the right thing” to improve community

health. Sound business practices, though

not necessarily proven using scientific

methods, are about using valid management and business practices to ensure

that health programs are “doing things

right” to get the best value from health

programs.

Evidence-based primary, secondary,

and tertiary prevention

The application of systematic methods to

review and analyze scientific evidence on

health interventions has led to the

development of guidelines that describe

the best population health and clinical

approaches to specific risks, diseases and

injuries. The intention in developing

guidelines is to systematically apply what

is known and not known about preventing, diagnosing, and treating diseases

and injuries to identify for health

professionals the interventions that are

most effective. In addition, this systemHealth

Problem

Risk Factor

Risk Factor

Direct/Indirect

 Contributing Factors

Direct/Indirect

 Contributing Factors

Direct/Indirect

 Contributing Factors

Intervention

Intervention

Intervention

Intervention

Intervention

Intervention

Intervention

Intervention

Intervention

Figure 7. Figure 7. Figure 7.

Applied epidemiology process (NACCHO 1991) Applied epidemiology process (NACCHO 1991)
16

atic process identifies areas where further

research is needed to fill gaps in the

evidence.

Primary and secondary prevention

guidelines have been developed for

clinical settings and are described in the

Guide to Clinical Preventive Services

(http://www.odphp.osophs.dhhs.gov/

pubs/guidecps/), developed by the U.S.

Preventive Services Task Force (1996).

This “clinical guide” provides recommendations and discussion for clinicians

on how to prevent and screen for

numerous priority diseases and injuries

and provides guidelines based on age

group and risk stratification.

Guidelines for prevention activities in the

community setting are being developed

and released in phases as the Guide to

Community Preventive Services by the

Task Force on Community Preventive

Services (2000). This “community

guide” will provide recommendations for

population-based interventions for health

promotion, specific disease and injury

prevention, and health protection.

Many guidelines are available that

recommend tertiary prevention (treatment and rehabilitation) interventions.

Disease treatment and rehabilitation

guidelines are called clinical practice

guidelines (CPGs). Most CPGs target

specific diseases, conditions, or symptoms. A Department of Defense and

Veterans Administration Workgroup has

developed CPGs for asthma, diabetes, and

a variety of other health conditions

(http://www.cs.amedd.army.mil/qmo/

Home.htm). Developing CPGs is a

complex task; therefore, it is not surprising that there is only a handful of

evidence-based guidelines available

today (see Evidence-based Primary,

Secondary, and Tertiary Prevention, in

Section IV).

“Evidence-based” business practice

Setting standards for business practice

requires the use of proven business and

program management tools. In the past,

standard operating procedures for

managing health services were often

based on military and civilian inspection

criteria. We now know that this is not

enough. Business tools, models, and

experience can help organizations

effectively meet and manage the demand

of their populations. The MHS Health

Care Reengineering Program (http://

www.tricare.osd.mil/hcr) is a forum for

sharing and retrieving experiences with

health services innovation. Within this

guide are tools to help organizations

forecast demand for products, resources,

and services (see Forecast Demand,

Section IV). Demand management

tools help MTFs and other organizations

manage demand for health services using

methods proven in commercial and

government health plans (see Manage

Demand, Section IV). Resource management tools such as business case analysis

and workload models help MHS organizations to manage capacity, project

future needs, and make long-term

realignment decisions. A few of the

many business and cost analysis models

are cost/benefit analysis, cost/utility

analysis, cost minimization, and costeffectiveness analysis (see below).

A limited discussion of business analysis

and management models in the context

of population health improvement is

presented under Manage Capacity, in

Section IV. Interested readers can learn

more about specific business analysis

tools for health services management in

the health management literature.

Cost-effectiveness

Cost-effectiveness analysis in population

health is a method of combining clinical

An MTF planner finds that acute exacerbation of asthma is among the most

common diagnoses resulting in acute visits to the outpatient clinics. Further

analysis reveals that most patients presenting acutely and who are

diagnosed with asthma are children. In the process of planning to

address this problem, the target population is identified as children

enrolled to the MTF and who are between ages 1 and 18 years. The

epidemiologic process determines several risk factors for acute

asthma including upper respiratory tract infection, exposure to

environmental tobacco smoke, ineffective use of prescribed preventive medications,

and even active smoking by some youth.

In pursuing exposure to environmental tobacco smoke as a risk factor for possible

intervention, factors are identified that directly and indirectly contribute to children

being exposed to environmental tobacco smoke.

A direct contributing factor for some children is that they live with an adult who

smokes in the home. An indirect factor that is modifiable is that many adults are

not aware of the effects their smoking inside the home has on a child’s asthma. The

planner is now close to identifying potential interventions for addressing the health

problem in the identified population.
17

helping agencies that are outside the MHS

programs and either on base or in the

nearby community (http://

www.thecommunityguide.org). Community outreach is needed to extend

beyond the boundaries of programs

managed within the MHS to partner with

the many community-based services that

so greatly impact the health of military

populations.

Information Management

Information management is critical to

population health. Assessing the health

status of populations is a data-rich and

information-intensive process. Planning

must link information about health

problems in the community with

information about available resources;

and the cyclical process is repeated using

periodic performance monitoring and

reassessment. Population health

information management must provide

actionable information that is datadriven and that drives data and

knowledge management and transfer.

Throughout the DoD, organizations

should have an information management strategy that incorporates high

quality data collection, proper epidemiologic and biostatistical analysis, interpretation, and dissemination; collection and

transfer of knowledge on best practices;

and comprehensive education.

Actionable Information

There is a growing demand for datadriven plans, policies and programs in

health agencies. The rapidly expanding

availability of health data and better tools

for collecting and analyzing data both

drives this demand and makes achieving

data-driven health operations more

challenging. Health agencies must be

able to effectively analyze and interpret

effectiveness with costs of health interventions. Cost-effectiveness analysis allows

comparisons of various interventions by

developing measures of the cost per

amount of “health” gained from an

intervention (using units such as lives

saved or cases prevented) (Turnock

1997). The increasing application of

cost-effectiveness analysis in population

health research is building a body of

information about the impact of interventions on the health of populations as a

function of the cost of implementing

health programs. Clearly, this information will be highly valuable to health

planners faced with prioritizing programs

(Maciosek 2001).

In summary, Force Health Protection,

worksite and community-based, and

TRICARE health plan programs can all

incorporate evidence-based interventions.

Force Health Protection programs can

employ evidence-based primary, secondary, and tertiary prevention in each of the

three pillars—fit and healthy force,

casualty prevention, and casualty

management. Military doctrine provides

the “business” evidence for how to apply

evidence-based prevention the “right

way” in military settings. The use of

evidence-based information, often in the

form of guidelines, will help the health

plan ensure that they are providing

effective and efficient services for beneficiaries. Finally, evidence strongly

supports the importance of assuring a full

complement of services is available to

achieve population health improvement

objectives for military communities.

Worksite and community-based programs can be developed using evidencebased interventions. Some of the most

effective programs will be provided by

data to identify community health

problems, establish policies and programs to address problems, and measure

progress in resolving problems. There is

also an established management axiom

“what gets measured gets done” (American Society of Public Administration

1998). Combining the demand for datadriven operations by health agencies with

the management axiom creates an

imperative for acquiring and utilizing

population health data: if what gets

measured gets done, then what needs to

be done must be measured. The

challenge is to translate the plethora of

health data available today into actionable information that is useful at the level

where policies and programs are developed, resourced, and implemented.

Figure 8 depicts the iterative nature of

population health information management, which directly mirrors population

health planning and performance

measurement. Health data on individuals and communities are collected

through information management tools.

These data include the distribution of

diseases, injuries, behaviors, occupation,

demographics, business and other

characteristics related to health and

health services. The data are retrieved,

analyzed, and interpreted to synthesize

health information for dissemination.

Information that is disseminated to

providers such as PCMs in primary care

clinics, community program managers,

or forward deployed health protection

teams, must be actionable at the level the

providers impact individual, worksite

(unit or command), and community

health. Actionable information will allow

providers to determine who needs what

services, and when and where the services

are needed. Providers use the population

health information to develop and deliver

health services to individuals and
18

communities. Similarly, the health data

are retrieved, analyzed, and interpreted to

support aggregation of information from

many communities to develop enterprise

level metrics. Enterprise level metrics

include measures of health status across

DoD communities, business measures

such as expenses and revenue, and

performance measures that elucidate

overall quality and efficiency of services

provided. Senior leadership at the

intermediate and headquarters levels use

metrics to develop the highest level plans,

policies and programs that cascade back

to providers at the “deck plate.”

Using Objectives for Improving Health

Status and for Monitoring Performance

If the health status of a population is to

be improved then there must be identified

Enterprise

Metrics

Actionable

Information

Clinical,

Community

& FHP

Programs

Headquarters &

Regional Leaders

Population

Health Data

Individuals &

Communities

IM

Tools

Plans, Policies, Programs

Health

Services

Figure 8. Figure 8. Figure 8.

Population health information management Population health information management

objectives for health that policies and

programs are designed to achieve.

Objectives are quantifiable measures of

the desirable effects of interventions that

are to be achieved by a certain point in

time. The Healthy People initiative and

similar State and local efforts have

embraced the use of health objectives to

prompt action and measure progress in

addressing health problems (McGinnis

and Maiese 1997). Health organizations

must use population-based objectives to

plan, resource, implement, and evaluate

programs to improve individual, worksite,

and community health. Progress

measurement can be easily linked to the

planning process when interventions have

carefully developed objectives. These

objectives should be measures of population health. Healthy People 2010 is a

national initiative to advance a comprehensive health promotion and disease

prevention agenda that includes 467

population-based objectives (HHS 2000).

The MHS, Regions, and MTFs may adopt

some of the objectives to target health

problems or develop unique objectives.

Leading Health Indicators and National Objectives for Improving Health

Healthy People 2010: Objectives for

Improving Health (http://

www.health.gov/healthypeople/document) presents a comprehensive set of

health objectives that captures objectives

for morbidity and mortality and objectives for risk factors and direct and

indirect determinants of disease, injury,

and disability. Healthy People 2010

objectives are intended to aid local health

initiatives, foster development of increas-
19

ingly detailed data, and measure

progress. However, there is no implied

priority for the objectives and communities and health organizations will use

objectives based on their specific priorities

(HHS 2000).

To create a snapshot view of progress

toward meeting the health objectives for

the nation, ten Leading Health Indicators

(Figure 9) were created to represent a

small subset of the 467 objectives in

Healthy People 2010. The 21 objectives in

the Leading Health Indicators are

examples of the comprehensive Healthy

People 2010 objectives that can be

adopted or adapted for local population

health programs.

Population-based objectives that have

clearly defined numerators and denominators will drive programs to demonstrate

results and allow measurement of

progress in population health. The

numerator must describe the health event

the intervention will modify, for example,

the number of children and adolescents

at Scott AFB who are overweight or obese.

The denominator must clearly describe

the target population for the intervention,

the number of children and adolescents

enrolled to Scott AFB. Objectives also

must include the direction the intervention is intended to move the measure

from its baseline, or current level, and

must be linked to a target to achieve by

an established time. The Healthy People

2010 objective for overweight and obesity

in children and adolescents is: Reduce

the proportion of children and adolescents who are overweight or obese. The

national baseline is 11 percent and the

target for the year 2010 is 5 percent (HHS

2000). Each objective must have a source

for appropriate numerator and denominator data to measure and improve

health. Sources for data should support

periodic measurement to monitor

progress over time. While it can be

difficult to find reliable ongoing sources

of data for many health problems, the

imperative to address a problem can drive

the identification and development of the

data that are needed.

Outcome, Impact and Process Measures

Community health efforts must be

monitored and evaluated for short,

intermediate, and long-term effectiveness.

Measuring the results of programs is

important to reinforce and improve

performance. In health programs, it is

how progress toward the vision for

community health is monitored.

Processes for monitoring and evaluation

can be divided into three levels, outcome,

impact, and process objectives

(NACCHO 1991; HHS 1993).

Health data used in assessment, surveillance and planning can be linked to

methods of evaluation through population-based objectives. In other words,

data used during the planning process to

develop objectives for interventions can be

the same data that support evaluation

and monitoring with objectives.

Health outcome objectives are typically

measured using long-term measures that

include life expectancy, quality of life, and

mortality and morbidity rates. It may

take a very long time to demonstrate

changes in health status outcomes

because much of the current burden of

mortality and morbidity is related to

chronic diseases (Rohrer 1999). While in

many cases, changes in morbidity and

mortality outcomes, such as communicable disease and injury morbidity and

mortality rates, can be demonstrated over

much shorter intervals. Programs, both

MHS-wide and local should develop true

outcome objectives for programs that

target health problems such communicable disease and injury morbidity and

mortality (Rohrer 1999).

Impact objectives incorporate intermediate and short-term measures of changes

in risk factors and direct and indirect

contributing factors for disease or injury.

Impact objectives may necessitate

measuring prevalence or incidence rates

of behaviors, environmental risks, and

biological risks such as hypertension and

hyperlipidemia. The time interval for

measuring changes in impact measures

may be as long as 3-5 years (NACCHO

1991).

There are two different ways to consider

process objectives. One type of process

objective is monitored by measuring the

services provided to populations over a

specific period of time; yielding population-based rates (NACCHO 1991). An

example would be measuring the

proportion of children who have received

recommended immunizations over a 12-

month interval. Receiving recommended

immunizations is a process of health

services, and some would call its measure

a process measure.

Another way to consider process measures

is to look at processes as the activities (or

tasks) within a program. In this context,

process objectives describe expected

counts of activities in an intervention

rather than population-based rates (HHS

1993). Both types of process objectives

are very useful for monitoring and

evaluating programs at the local level

and should be measurable at intervals of

1-2 years (NACCHO 1991).

The most frequently collected population
20

Leading Health Indicator

Physical Activity

Overweight and Obesity

Tobacco Use

Substance Abuse

Responsible Sexual Behavior

Mental Health

Injury and Violence

Environmental Health

Immunizations

Access to Health Care

Corresponding Objectives

22-7. Increase the proportion of adolescents who engage in vigorous physical activity that

promotes cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion.

Target: 85%; baseline: 64%

22-2. Increase the proportion of adults who engage regularly, preferably daily, in moderate

physical activity for at least 30 minutes per day. Target: 30%; baseline: 15%

19-3c. Reduce the proportion of childhood and adolescent who are overweight or obese.

Target: 5%; baseline: 11%

19-2. Reduce the proportion of adults who are obese. Target: 15%; baseline: 23%

27-2b. Reduce cigarette smoking by adolescent. Target: 16%; baseline: 36%

27-1a. Reduce cigarette smoking by adults. Target: 12%; baseline: 24%

26-10a. Increase the proportion of adolescents not using alcohol or any illicit drugs during the

past 30 days. Target: 89%; baseline: 77%

26-10c. Reduce the proportion of adults using any illicit drug during the past 30 days.

Target: 3%; baseline 6%

26-11c. Reduce the proportion of adults engaging in binge drinking of alcoholic beverages

during the past month. Target: 6%; baseline: 16%

25-11. Increase the proportion of adolescents who abstain from sexual intercourse or use

condoms if currently sexually active. Target: 95%; baseline: 85%

13-6. Increase the proportion of sexually active persons who use condoms.

Target: 50%; baseline: 23%

18-9b. Increase the proportion of adults with recognized depression who receive treatment.

Target: 50%; baseline 23%

15-15. Reduce deaths caused by motor vehicle crashes.

Target: 9 per 100,000; baseline: 15.8 per 100,000.

15-32. Reduce homicides. Target: 3.2 per 100,000; baseline: 7.2 per 100,000

8-1a. Reduce the proportion of persons exposed to air that does not meet the U.S. Environmental

Protection Agency’s health-based standards for ozone. Target: 0%; baseline: 43%

27-10. Reduce the proportion of nonsmokers exposed to environmental tobacco smoke.

Target: 45%; baseline 65%

14-24. Increase the proportion of young children who receive all vaccines that have been

recommended for universal administration for at least 5 years. Target: 80%; baseline: 73%

14-29a & b. Increase the proportion of noninstitutionalized adults who are vaccinated annually

against influenza and ever vaccinated against pneumococcal disease.

Target (influenza): 90%; baseline: 63%.

Target (pneumococcal): 90%; baseline: 43%

1-1. Increase the proportion of persons with health insurance.

Target: 100%; baseline: 86%

1-4a. Increase the proportion of persons who have a specific source of ongoing care.

Target: 96%; baseline: 86%

16-6a. Increase the proportion of pregnant women who begin prenatal care in the first trimester

of pregnancy. Target: 90%; baseline: 83%

Leading Health Indicators and Corresponding Healthy People 2010 National Objectives

Figure 9. Healthy People 2010 Leading Health Indicators (HHS 2000) Figure 9. Healthy People 2010 Leading Health Indicators (HHS 2000)
21

health performance measures should be

those that discern the effects of local

programs on near-term health objectives,

typically the priority impact or process

measures. Less frequent measures, such

as overall health status or health outcome

measures, should be emphasized in less

frequent, long-term program evaluations.

MTFs and local communities may not be

able to demonstrate how interventions

result in changes in long-term health

outcomes. Therefore, measuring progress

toward impact and process objectives for

interventions may be sufficient if

interventions that are known to improve

health outcomes are chosen (i.e.,

evidence-based interventions) (APHA

1991).

Increasingly, health data are being used

to support population-based health

planning and measurement of progress

(HHS 2000). Demonstrable changes can

be found in the Healthy People initiative

coordinated by the U.S. Department of

Health and Human Services. In the

succession of decennial health objectives

for the Nation included in Healthy People

reports, there has been increasingly

robust epidemiologic information about

the distribution and causes of disease and

disability in the United States. There also

have been an increasing number of

health objectives to reflect the breadth

and depth of health problems among

communities in the United States. More

states and local jurisdictions are using the

approach of Healthy People to support

health planning and to establish their

own health objectives.

The use of outcome, impact, and process

objectives, and performance measures, or

metrics, is the “medium” or “language”

of conducting quality clinical, worksite,

and community-based services and Force

Health Protection. Quality health services

are in the hands of each provider.

Providers typically practice based on the

information they learned in training.

The explosion of information availability

has opened incredible opportunities for

bringing current, critically analyzed

information to providers in a manner

that is immediately relevant and useful in

making health services decisions.

Therefore, use of knowledge management

principles and continuous monitoring of

performance effectiveness are crucial to

ensuring the quality of all health services

in the MHS. Health status and program

measures that are derived from objectives

are the best tools to accurately describe

and monitor effectiveness of health

services provided.

Knowledge Management and Transfer

The MTFs, Regions, and other offices

within the MHS and DoD can operate as

learning organizations by seeking out

and adopting or avoiding practices based

on the experience of others. This requires

that knowledge be collected, organized

and disseminated within the MHS

agencies and between MHS offices and

peer organizations in the private and

government sectors.

The explosion of information technology

over the last quarter century has ensured

that there is no shortage of health

information from which to learn and

improve. Population health improvement must benefit from the dawning

knowledge age. The MHS and DoD can

employ enterprise level knowledge

management and transfer strategies that

ensure system-wide visibility to population health “knowledge.” The strategies

will include methods for collecting

lessons learned and best practices,

analyzing and evaluating the experiences

of others and new research to identify

what will and will not work in MHS

programs. The population health

knowledge that is collected will be

managed to maintain currency and to

make it easy for others to find and utilize

the knowledge. It will be disseminated, or

pushed, out to appropriate levels of the

enterprise to benefit from every opportunity to learn.

Finally, a major strength of the MHS is

the control of educational process. To

cope with change and foster a learning

organization, while rapidly changing the

culture of the organization, a comprehensive program of formal education

needs to be established. Such a curriculum must impart knowledge to all levels

of the organization as well as to suppliers

and customers. Education in the

principles, processes and tools for

population health improvement must be

incorporated into each Service’s education programs. The basic tenets must be

taught to the widest audience and rolespecific education and training are

required for each member of the health

services team. Military and civilian staff

members and managed care support

contractors must understand the basic

principles of population health improvement and the specific goals. The

investment of time, money and effort

toward these education and orientation

goals will be returned many-fold in the

form of facilitated start-up as well as

better clinical outcomes and quality of

care.
22

Resources for Population Health

Improvement

Population health improvement in the

DoD cannot become a reality unless

resources (staff, space, money, etc.) are

aligned with population health improvement policies and programs. Resources

must be distributed among the policies

and programs under the areas of Force

Health Protection, worksite and community-based, and MTF programs and the

TRICARE health plan so that each

program area maximally contributes to

improving the health of military communities. It takes unrelenting planning and

difficult decision-making to ensure that

scarce resources are provided to develop

and implement those programs that are

most effective in achieving population

health objectives.

The current portfolio of programs has

been developed over many years of

planning, programming and budgeting.

Medical readiness programs have

appropriately continued as a top-priority

in support of the National Defense

Strategy. However, the current Force

Health Protection doctrine may drive new

programs to ensure the three pillars of

healthy and fit force, casualty prevention, and casualty care and management are all in place.

Resource requirements to maintain and

improve programs under the TRICARE

health plan have put continued pressure

on the funding for all programs in the

MHS. This pressure will continue

indefinitely as the beneficiary population

ages and as health care technology drives

cost increases ahead of overall inflation.

Public law mandates TRICARE benefits

and therefore many of the programs

under the TRICARE health plan drive

“must pay” resource requirements. Such

requirements threaten to squeeze out new

programs for population health improvement and programs that are not mandated by law. For example, many

worksite and community-based programs

that might be more cost-effective than

some under the TRICARE benefit may not

receive adequate resources to be effective

or may, unfortunately, receive no funding

at all.

There are several components of population health improvement outlined in this

plan and guide that require new or

renewed attention in the resource

prioritization processes. In addition to

the redirection of resources to new Force

Health Protection programs, enhanced

primary and secondary prevention

benefits under TRICARE, and worksite

and community-based programs, the

DoD must build a population health

improvement capacity improvement capacity at each level of improvement capacity

the enterprise. The functions and benefits

of population health support activities

needed at the MHS and Region level are

described in following sections. A

plethora of functions needed to support

population health at MTFs are described

in detail in Section IV. Some of the key

functions of population health support

that must be inculcated in programs and

funded accordingly include information

management, education, community

health planning, applied epidemiology,

health services research to identify

effective evidence-based interventions,

and function-driven information

technology.

The MHS must also increase the employment of distinct professional skills in

order to build a population health

improvement capacity. For example,

professionals who have skills in data

development and analysis, applied

epidemiology, health education, health

services research, program evaluation,

and community health planning are

required at the MHS and Region levels.

Smoking has been identified as the major risk factor for not just one but many of the

top health problems in the local military community. Numerous direct and indirect

contributing factors and possible interventions to mitigate them

have also been identified. The next challenge is to review the

evidence on possible interventions to find effective, evidence-based

activities to include in smoking reduction programs on and near

the base. The evidence will show, for example, that no single

intervention is, by itself, sufficient to greatly impact smoking in a

community. In fact, the best approach is to use a portfolio of clinic-based, worksite,

and community-based policies and programs (examples are presented in the

sections below). It is essential to set achievable near and intermediate term objectives for the programs and identify sources for baseline data and for data that will be

used to monitor progress. Objectives from Healthy People 2010 can be adapted, for

example:

1. Reduce the proportion of active duty personnel who smoke cigarettes. Target (3

yrs): 25%; baseline 30%.

2. Increase smoking cessation during pregnancy for enrolled women. Target (1 yr):
23

MTFs and other program offices need

additional prevention and population

health trained professionals such as

preventive medicine and public health

specialists, community health educators,

health promotion specialists, biostatisticians, and data analysts.

Inspection Item

An effective means for ensuring that

population health improvement initiatives become a reality across the MHS is to

insert the core activities into each

Service’s health services inspection

program. This is consistent with the

dynamic progression of inspections to

remain ahead of the best principles and

practices in the health services industry

and MHS-specific requirements. A set of

population health process criteria used

during inspections at AF MTFs is

available through the Population

Health Support Office (https://

phsd.afms.mil/PHSO/).

Incorporating Utilization

Management and Review

Some readers may recognize that many

of the principles, processes, and tools

discussed have evolved from earlier

concepts of utilization management

(UM) and utilization review (UR).

Utilization Management and Utilization Review plans and processes

currently in place should be continued

where they have proven valuable

(Health Affairs Policy http://

tricare.osd.mil/policy/fy98/

umpd9831.html). Selected elements of

UR and UM are key tools for improving

the health of the MHS beneficiaries (see

Forecast Demand, Manage Demand,

and Manage Capacity, Section IV).

These elements must be included in

population health improvement programs. Under TRICARE, population

health improvement plans in the Direct

Care System must be integrated with the

Managed Care Support Contract (MCSC)

network as well as other MTFs in the

region, including coordination with

Centers of Excellence (COE). For

population health improvement to be

effective, implementation strategies must

be comprehensive, systematic, and

ongoing throughout the continuum of

care. Integrated strategies should include

all aspects of medical, surgical, and

mental health care, both inpatient and

Healthcare

Delivery

System EVALUATE IMPLEMENT

PLAN

EVALUATE IMPLEMENT

PLAN

Model

System

Single Loop

Learning

Double Loop

Learning

Current research shows that environmental stimuli perceived as a problem leads

individuals (and organizations and other

systems) to learn something new to solve

that problem. There is a problem

identified; one then gathers the necessary

information and applies it to correct the

problem. In a simpler example: the

thermostat is set at 75o

F, the ambient

temperature is 70oF, so the furnace is

turned on. In such cases, we apply

information to get the “right outcome.”

This is the case of single loop learning.

In the case of double loop learning, we

question the paradigm. Is the way that

we are solving the problem the correct

way? More simply, is the thermostat set at

the right temperature? Double loop

learning is all about thinking about what

we do to explore the underlying patterns

we use to learn and solve problems.

Double loop learning is a reflective

practice.

If we are to understand and improve how

we learn and solve problems, we must be

able to step out of the subjective realm of

experiencing the problem and objectively

observe ourselves learning and applying

the problem solving style we use. We

must watch what we do, how we do it,

and how we feel as we do it, all while we

outpatient, encompassing all clinical and

community services that impact on

population health.

Utilization management programs can

further evolve to effective population

health improvement programs through

the use of evidence-based, best clinical

and business practices (benchmarking).

Implementation of these practices must

be tailored to the facilities and the

population they support. One goal is to

reduce unwarranted variation in the

management of acute and chronic

diseases and injuries in the enrolled
24

population. Population health improvement plans will use the best of UM and

UR. Patient and staff education will be

essential. There will be an increased focus

on health promotion and prevention of

disease and disability. Primary care

managers (PCMs) will be required to

identify sub-populations within their

panels of patients. There must be

feedback to PCMs on the individual and

aggregate health of their patients and the

appropriate use of medical resources to

accomplish this.
25

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Model Standards. Washington, DC: APHA.

Available at http://www.apha.org/media/

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American Society for Public Administration. 1998. Performance Measurement:

Concepts and Techniques. Washington,

DC: American Society for Public Administration.

Centers for Disease Control and Prevention (CDC). 1993. Mortality trends for

selected smoking-related cancers and

breast cancer—United States, 1950-1990.

Morbidity and Mortality Weekly Report

42(44):857, 863-866.

Centers for Disease Control and Prevention (CDC). 1999. Tobacco use—United

States, 1900-1999. Morbidity and

Mortality Weekly Report 48(43):986-993.

Fielding, JE, CG Husten and MP Eriksen.

1998. Tobacco: health effects and control.

In Public Health and Preventive

Medicine. ed. RB Wallace. Samford, CT:

Appleton and Lange.

Institute of Medicine (IOM). 1988. The

Future of Public Health. Washington,

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Kindig DA. 1997. Purchasing Population

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Michigan Press.

Maciosek, MV, et al. 2001. Methods for

priority setting among clinical preventive

services. American Journal of Preventive Medicine 21(1):10-19.

McGinnis, JM, and WH Foege. 1993.

Actual causes of death in the United

States. JAMA 270(18):2207-12.

McGinnis, JM, and DR Maiese. 1997.

Defining mission, goals, and objectives.

In Principles of Public Health Practice,

ed. FD Scutchfield and CW Keck. Albany,

NY: International Thomson Publishing.

National Association of County and City

Health Officials (NACCHO). 1991.

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Public Health (APEX/PH). Washington,

DC: NACCHO. Information available at

http://www.naccho.org/project47.cfm.

National Cancer Institute (NCI). 2001.

SEER Cancer Statistics Review 1973-

1998. Bethesda, MD: National Cancer

Institute. Available at http://

seer.cancer.gov/Publications/

CSR1973_1998.

National Center for Health Statistics

(NCHS). 2000. Health, United States,

2000. Hysattsville, MD: U.S. Government

Printing Office.

Public Health Functions Steering

Committee. 1995. Public Health in

America. Washington, DC. http://

web.health.gov/phfunctions/public.htm.

Rohrer, JE. 1999. Planning for community-oriented health systems. Washington,

DC: American Public Health Association.

Suen, J, A Cooper and M Taylor. 1995.

Analysis of the current status of public

health practice in local health departments. American Journal of Preventive

Medicine S-11(6):51-54.

Task Force on Community Preventive

Services. 2000. Introducing the Guide to

Community Preventive Services: methods,

first recommendations and expert

commentary. American Journal of

Preventive Medicine S-18(1):1-142.

Turnock, BJ. 1997. Public Health: What It

Is and How It Works. Gaithersburg, MD:

Aspen Publishers.

Tyler, CW, and RC Dicker. 1997. Health

data management for public health. In

Principles of Public Health Practice, ed.

FD Scutchfield and CW Keck. Albany, NY:

International Thomson Publishing.

U.S. Department of Health and Human

Services (HHS). 1993. Planned Approach

to Community Health (PATCH). Atlanta,

GA: U.S. Department of Health and

Human Services. Available at http://

www.cdc.gov/nccdphp/patch/index.htm.

U.S. Department of Health and Human

Services. 2000. Healthy People 2010. 2nd

ed. with Understanding and improving

health and objectives for improving

health. 2 vols. Washington, DC: U.S.

Government Printing Office.

U.S. Preventive Services Task Force. 1996.

Guide to Clinical Preventive Services.

2nd ed. Alexandria, VA: International

Medical Publishing.

Wallace, RB. 1998. Public health and

preventive medicine: trends and guideposts. In Public Health and Preventive

Medicine. ed. RB Wallace. Samford, CT:

Appleton and Lange.

World Health Organization (WHO). 2001.

http://www.who.int/aboutwho/en/

definition.html: accessed February 20,

2001.

References
26
27

Force Health

Protection

Force Health Protection (FHP) is the

vision for the portfolio of programs that

are needed to protect fighting forces. It is

based on the concept of total life-cycle

health support. The total life-cycle

support concept embraces the challenge

to improve the health of

servicemen and women from

their first entrance into the

military through their entire

military service, including

deployments. The FHP vision

also recognizes that the most

valuable and complex weapon

systems in the U.S. military are

its Soldiers, Sailors, Airmen, and

Marines.

Force Health Protection doctrine

describes three inter-related

pillars—healthy and fit force,

casualty prevention, and

casualty care and management. It

also outlines the infrastructure that must

be in place to achieve the FHP objectives

under each of the pillars.

A healthy and fit force must be maintained as a given status for military

forces. This requires programs in the

areas of disease and injury prevention,

health promotion (including mental

health), and occupational health. Some

of the functions needed include physical

training, family support, periodic health

assessments and clinical preventive

services. It also requires that service

members and their families have ready

access to the TRICARE health plan.

Casualty prevention is designed to

counter two types of threats; those from

environmental and occupational health

hazards and threats posed directly by

enemy actions. Environmental and

occupational health hazards have

consistently caused the greatest numbers

of casualties in military operations.

Casualty prevention programs target

disease and non-battle injury (DNBI).

Casualty prevention to counter threats

from enemy action relies on efforts to

reduce enemy capabilities before casualties occur.

While FHP is no longer centered just on

medical care for ill or injured forces,

casualty care and management programs

must ensure the best medical capabilities

are in place to treat DNBI and combat

casualties. Casualty care involves a

continuum for stabilizing casualties. The

continuum spans from first response

through a critical-care-capable evacuation system.

The FHP capstone document (http://

www.dtic.mil/jcs/j4/divisions/mrd/)

provides extensive detail for FHP activities. MHS FHP links are found at http://

www.tricare.osd.mil/readiness/

forcehlth.html.

Section II.

Active Duty service members who are worldwide deployable do not typically manifest

clinical symptoms of some of the common chronic diseases that result from

smoking. This is not to imply, however, that smoking is not a

threat to military operations. Force Health Protection doctrine

calls for a fit and healthy force and this means that health-risking

behaviors must be addressed. This is critical to improving the

resistance and resiliency of military troops. In the theater of

operations, disease and non-battle injury (DNBI) causes more

casualties than does combat. Upper respiratory tract infections have been among

the leading DNBI mission-impacting health events in all major military contingencies. Smoking is associated with an increased incidence of upper respiratory tract

infections and with increases in lost duty days from many other illnesses.

Smoking can be a major health threat in the context of Force Health Protection

programs. Commanders and medics must engage to prevent smoking initiation by

troops and to help smokers quit. These should be mission-essential initiatives for

unit readiness and for the health of servicemen and women.
28
29

Worksite and

Community-based

Programs

Scope

The Military Health System can have a

significant positive effect on population

health through worksite and communitybased programs. The scope of interventions that can be implemented in worksite

and community-based venues is very

broad. Programs to reduce unhealthy

behaviors, protect against exposure to

toxins, and conduct disease and injury

surveillance may be part of occupational

health activities at worksites. Environmental health services, school-based

physical activity and nutrition programs,

and media campaigns to promote

healthy lifestyles are examples of

community-based programs organized by

public health, community health, and

private agencies. Worksite and community-based programs for population

health improvement should address areas

of health promotion and protection

(including environmental health),

disease and injury prevention and

screening, and public health surveillance.

This edition of the Population Health

Section III.

Improvement Plan and Guide does not

describe the depth and breadth of MHS

worksite and community-based programs

or provide specific guidance for developing and implementing such programs.

Some examples of specific interventions,

in a few key areas, are outlined to

increase momentum for building

capacity in worksite and communitybased programs across the MHS. Resources for information about many of

the existing worksite and communitybased programs in the three Services are

provided as well.

Examples of Interventions

Changing risky behaviors

• School-based physical activity

programs for all age groups

• Physical activity programs for 65

years old and older adults

• Initiatives addressing availability of

safe recreation and fitness sites (e.g.,

parks, trails, fitness centers)

• Community-wide nutrition education programs in schools, restaurants, shopping sites

• Traffic safety programs

• Tobacco use prevention and cessation programs

Reducing specific conditions,

diseases, injuries and impairments

• Community-baseed programs

providing age-specific clinical

screening, counseling and immunizations

• Community support programs for

mentally disabled, physically

disabled, disadvantaged, older

adults, and those with chronic or

disabling conditions

To reduce smoking related illness requires a portfolio of measures that prevent

initiation of smoking, promote smoking cessation and protect

non-smokers from harmful tobacco smoke. Recent emphasis has

been placed on the importance of effective worksite and community-based programs to reduce smoking. Worksite policies that

limit where smoking is allowed contribute to the negative image of

smoking and protect non-smokers from exposure to environmental tobacco smoke. Employer-sponsored policies and programs can provide incentives to smokers who successfully quit smoking. Community laws and enforcement programs can restrict access to cigarettes by youth. School-based and faithbased education programs help teach children how to resist the temptation to

experiment with cigarettes. Media campaigns effectively counter tobacco marketing

and tobacco taxes can increase the price of cigarettes to reduce tobacco consumption.

Finally, worksite and community-based programs can help connect smokers with

clinical services to assist with smoking cessation. (Task Force on Community
30

• Unintentional injury prevention

programs (e.g., motor vehicle

accidents, falls, drowning, fire,

poisoning, head and spinal cord

injuries)

• Drug and alcohol treatment

programs

• Tobacco use prevention and cessation programs

• Chronic disease prevention and

screening programs (e.g., cancer,

heart disease, and diabetes)

• Family planning

• Maternal and infant health

• Oral health (dental and periodontal)

• Societal health issues associated with

school drop-outs, homicides,

Service Resources

Health Promotion

Army: http://chppm-www.apgea.army.mil/dhpw

Navy: http://www-nehc.med.navy.mil/hp/index.htm

Air Force: https://www.afms.mil/op_prev/hlthprom.cfm

Environmental Health

Army: http://chppm-www.apgea.army.mil/services/dehedir.htm

Navy: http://www-nehc.med.navy.mil/ep/index.htm

Air Force: https://www.afms.mil/occ_env/indexnew.htm

DoD: http://www.denix.osd.mil/denix/welcome.html

Occupational Health

Army: http://chppm-www.apgea.army.mil/services/dohsdir.htm

Navy: http://www-nehc.med.navy.mil/occmed/index.htm

Air Force: https://www.afms.mil/occ_env/indexnew.htm

Community Health

Air Force: https://www.afms.mil/occ_env/indexnew.htm

Reference

Task Force on Community Preventive

Services. 2001. Recommendations

regarding interventions to reduce tobacco

use and exposure to environmental

tobacco smoke. American Journal of

Preventive Medicine 20(2S):10-15. The

Task Force on Community Preventive

Services reports on tobacco can be

accessed at http://

www.thecommunityguide.org/

home_f.html.

suicides, physical and mental abuse,

violence in the schools

• Occupational safety and health

programs

Addressing environmental and

ecosystem challenges

• Water borne and food borne illnesses

• Air pollutants (e.g., environmental

tobacco smoke)

• Toxic agents

• Solid-waste contamination

• Recycling programs
31

Military Treatment Facilities (MTFs) have

the majority of responsibility for providing services mandated under TRICARE.

In this regard, MTFs are essentially the

operational units for the military health

plan. This section is intended to provide

guidance to MTFs on the key processes,

roles and tools to implement the principles of population health improvement.

Military Treatment Facility

Population Health Offices

One approach to consider at the MTF is to

designate an office for population health

activities. This office would function to

coordinate, for the Commander, the

various programs and processes of

population health improvement. The

population health office would likely

interface with Regional Lead Agent,

parent Service, and Service intermediate

command population health offices and

would collaborate with other MTF

population health offices.

A critical role for the population health

office is to identify and develop the

information management capacity

needed to implement population health

improvement activities. The office will

help personnel at the base level to use

health information to support planning,

implementing, and evaluating health

improvement programs. Also, the

population health office can take the lead

in developing and managing a worksite

and community-based health plan,

including specific objectives for the near

and intermediate term.

The MTF must have an office that is

responsible for knowledge management

as well. The MTF will want full visibility

and participation as successes and

failures are shared across the enterprise,

new tools are developed and deployed,

and new interventions are published.

Introduction to MTF Key

Process Elements

The Population Health Improvement

process schematic (Figure 10) shows how

seven key process elements work in

sequence to support the overall concept of

population health improvement at the

MTF. The process elements represent

major functional areas of health service

delivery within the MHS. In simplistic

terms there are two factors to the

equation; the demand on the system and

the capacity of the system to complete the

mission. Basic laws of economics state

that a gap will exist between these two

factors. Doctrine or management

paradigms exist to minimize this gap.

To develop effective policies, plans, and

programs, the target populations must be

known (Element 1: Identify the Population). This population is then grouped

into sub-populations based upon various

characteristics that differentiate health

service needs. These sub-populations are

then identified, flagged and tracked

through the system to optimize their

health status. Enrollment is one way to

identify and define the population.

Standardization of the enrollment process

is required to assure continuity of care

and to minimize inefficiencies across the

vast geographic and service regions.

Having identified the target populations,

the future health service needs of the

populations are estimated (Element 2:

Forecast Demand). Forecasting demand

identifies what types and amounts of

primary, secondary, and tertiary prevention services will be health promotion and

health education, determine the staffing

Section IV.

Military Treatment

Facility Implementation Guide
32

and resources necessary to provide

individual, worksite, and communitybased health promotion and health

education.

Once the population has an assessment of

current health status, to include projected

intervention and prevention needs,

appropriate providers can be assigned

and a forecast of expected clinical

demands can be created and modeled.

These forecasts will help to determine the

various strategies and tools required in

managing demand (Element 3: Manage

Demand). This is one side of the

equation for optimizing the MTF.

Demand management focuses on

efficient and effective use of limited

resources by reducing inappropriate

demand and increasing appropriate

demand for services. Unmanaged

demand creates unnecessary bottlenecks

that slow the delivery of health care. In

the short term there are management

strategies that can decrease the demand

for health care. In the long term there

are self-care and wellness activities that

will reduce the overall need for health

care. To balance the system, strategies of

risk reduction and chronic disease and

condition management must address the

needs of the population while maximizing the efficiencies of the system.

The next process component is the

capacity of the system to provide intervention and prevention services. In this

process (Element 4: Manage Capacity),

limited resources must be prioritized and

allocated to minimize the gap that exists

between the demand and the resources. It

is at this point that previous efficiency

efforts were directed. These include UM

and UR. Tools to help decrease the overutilization of scarce resources are then

identified in process element four.

Element 5 is Evidence-based Primary,

Secondary, and Tertiary Prevention.

Many preventable acute and chronic

conditions place great demand on the

MHS. The goal is to move from expensive

tertiary interventions to less costly

primary and secondary prevention

strategies. Tools such as clinical practice

guidelines (CPGs), clinical pathways,

disease and condition management, and

discharge planning will be essential in

the transition to a prevention-based

health system.

It must be acknowledged that the greatest

impact on the health of communities has

been made through population health

efforts that involve many facets of the

community and not just the medical care

system (e.g., the recent decrease in suicide

rate within the USAF). Community

involvement (Element 6: Community

Outreach) brings the leaders of a

community together to solve health issues

that require a cooperative effort.

Finally, for any system to excel and

remain on course, comprehensive

measures of the processes, impacts, and

outcomes that lead to success must be

developed (Element 7: Analyze Performance and Health Status). Ideally

metrics collected within the system

should validate models of the system and

provide actionable information to

stakeholders that allows for course

corrections and system improvement.
33

Figure 10. 7 PHI Key Process Elements Figure 10. 7 PHI Key Process Elements

7 PHI Key Process Elements

1. Identify the

Population

3. Manage

Demand

6. Community

 Outreach

7. Analyze

Performance

& Health

Status

2. Forecast

Demand

Healthy Community

MHS

5. Evidence-Based Primary,

Secondary, & Tertiary

Prevention

4. Manage Capacity

Optimize Clinical System
34
35

Concepts

The foundation of population health

improvement doctrine is the accurate

identification of populations, association

of individual beneficiaries with accountable providers, and health assessment of

all individuals within the community.

The MHS has established a policy for

enrollment of TRICARE beneficiaries to

MTFs (OASD[HA} Policy 00-001, Policy

to Improve Military Treatment Facility

(MTF) Primary Care Manager Enrollment Capacity: http://

www.tricare.osd.mil/policy/ha00pol/

clin00_001.html). At MTFs, the population of interest may be the TRICARE

enrollees who are enrolled to MTF

providers. Military Treatment Facilities

may also be interested in the population

of “users” or potential “users” of MTF

services, both enrollees and beneficiaries

who are not enrolled. To achieve the

levels of effectiveness in improving health

and managing health resources that are

seen in the best health plans, three

processes must be in place:

 Processes to promptly enroll

beneficiaries

 Assignment to an individual Primary

Care Manager (PCM)

 Health assessment and stratification

processes

All three processes are necessary to

accurately identify individuals and groups

for MTF, worksite, and community-based

programs and to have a reliable assessment of the distribution of lifestyle,

behavioral, and environmental risk

factors and diseases and injuries.

Processes

Enrollment Processing: Enrollment Processing: The enrollment process begins when an eligible

beneficiary chooses to receive healthcare

under the auspices of TRICARE Prime.

Enrollment is a collaborative process

between base/post, MTF, Managed Care

Support Contractor (MCSC), and the

beneficiary. The enrollment process has

two steps. The first is administrative

enrollment and should be accomplished

within the first two weeks of arriving on

station (Active Duty). Administrative

enrollment involves completion of the

Enrollment Application and assignment

of a PCM by name. There are efforts

underway to automate administrative

enrollment for active duty. Enrollment at

a new station will trigger the transfer of

enrollment from the previous station.

The second step, Health Evaluation

Assessment Review (HEAR) Survey

completion, should be completed within

60 days of arriving on station. Ideally,

completion of the HEAR Survey is

accomplished at the time of administrative enrollment to aid in the assignment

of a PCM.

Enrollment processes are much more

uniform and timely since the deployment

of the National Enrollment Database

(NED) program in July 2001. NED brings

new enrollment forms, enrollment

computer applications, and enrollee

identification cards that achieve uniformity across the MHS. NED facilitates the

portability of enrollment when enrollees

move within and between TRICARE

Regions. NED policies and procedures

minimize the steps necessary to maintain

enrollment when individuals and families

move from one Region to another.

Assignment to PCMs: Assignment to PCMs: Primary care

manager assignment is the cornerstone

for population health management at the

MTF. The PCM is responsible for managing the health of a group of individuals

throughout the continuum of care.

Assignment of a PCM should reflect a

consideration of who is best suited to

oversee the necessary interventions and

prevention needs of that individual. A

primary care manager is typically a

family practitioner, internist, pediatrician,

obstetrician/gynecologist, or general

practitioner; however, with appropriate

supervision by a designated privileged

provider, a nurse practitioner, nurse

midwife, physician assistant, resident

physician, or independent duty corpsman

may also serve as a PCM. Physician

specialists can serve as PCMs if they have

been designated to do so by the Commander. This makes sense for patients

with significant illnesses that will require

the majority of their care to be provided

by the specialist (e.g., oncology patients

and renal dialysis patients). Designated

specialist PCMs must affiliate with PCMs

who are able to provider or coordinate the

routine care that the specialist would not

otherwise provide.

Current MHS policy encourages maximum flexibility for enrollees to choose a

PCM based on personal preference and

any unique health needs they may have.

Primary care manager assignment is not

uniform, however, and each MTF has

specific protocols, processes and constraints that must be considered at the

time of enrollment and PCM assignment.

Region Lead Agents strive to maintain

current lists of available PCMs at MTFs.

Military Health System policy requires a

by-name designation of a PCM for every

enrollee (DoD(HA) Policy 99-00033,

Individual Assignments to Primary Care

Managers by Name [http://

www.tricare.osd.mil/policy/ha99pol/

clin9933.htm]). Primary Care Manager

by Name (PCMBN) drives the need for a

Identify the Population
36

process at every MTF for reassigning

enrollees to a new PCM when providers

move to a new duty station. The process

should be as transparent to enrollees and

providers as possible. The objective is to

maintain continuity and quality of

services throughout the enrollment

period. The process must continue to

maximize enrollee preferences and

unique health care needs when reassignment to another PCM is necessary.

Health Assessment: Health Assessment: Completion of a

health assessment survey is an essential

part of the enrollment process. The

current MHS strategy to gather information on the health status and risk factors

on every enrollee is to use self-reporting

tools (SRTs). Self-reporting tools let

individuals or their guardians provide

personal health information to the MHS

including demographic, disease and

injury, and risk factor data. The SRT

currently employed in conjunction with

enrollment is the Health Evaluation

Assessment Review, or HEAR. The HEAR

survey is a tool that assists the health plan

and individuals’ PCMs in reviewing

individual health status and also

managing care for their enrolled

populations. This tool provides information related to health risk behaviors and

projects demand for services, to include

the need for prevention, case management, and disease management programs.

Roles

 Many offices have a part to play in

enrollment processing, assignment of

PCMs, and completing health assessments. The following outline lists many

of the specific tasks that are the responsibility of the involved offices.

Base Responsibilities:

 TRICARE Prime enrollment will be

included in base inprocessing for

active duty and their family members as available.

 Enrollment will be included in the

inprocessing/outprocessing checklist.

Military Treatment Facility Responsibilities:

 Compose and maintain an enrollment memorandum of understanding (MOU) with the contractor

 Ensure that Lead Agent has reviewed

the contract and Memorandum of

Understanding (MOU)

 Oversee the enrollment process

 Provide an up to date PCM provider

list to the MCSC per MOU

 Ensure that the HEAR Survey is in

the patient’s record and have a

process to ensure review of this

document

Managed Care Support Contractor/

Enrollment Agent Responsibilities:

 Be on site at the base inprocessing

center to the extent possible

 Have a process in place to capture all

beneficiary enrollments

 Provide guidance to the enrollee on

selection of a PCM based on the

current PCM provider list

 Assign PCMs as needed per MOU

 Assign enrollees to PCMs at the MTF

until the maximum capacity is

reached in accordance with the MOU

 Be present at base orientations

 Use the standardized TRICARE

enrollment application form for all

enrollments and transfers

 Use Defense Eligibility Enrollment

Review System (DEERS) Desktop

application to process enrollments,

dis-enrollments, and transfers

 Provide and encourage completion

of the HEAR Survey while enrolling

 Process and analyze HEAR data and

send reports to individuals and PCMs

 Provide HEAR data in electronic

form to Regional Lead Agent offices

 Provide each beneficiary with

fulfillment material per regional

contract (i.e. summary of benefits,

self-care books

Beneficiary Responsibilities:

 Active Duty personnel must transfer

enrollment during base inprocessing

by completing the Enrollment

Application and select or receive a

PCM assignment by name.

 Complete administrative enrollment

within the first two weeks of arriving

on station.

 Family members of AD are encouraged to make an informed choice

concerning enrollment and learn

about the TRICARE program.

 Complete the HEAR Survey within 60

days of arriving at a new station
37

Tools

Many tools are available to help planners

and providers at MTFs, Region Lead Agent

offices, Headquarters, and program

management agencies with identifying

populations, enrollee beneficiaries, and

assessing the distribution of health

problems and risk factors within populations.

Information about the National National

Enrollment Database (NED) Enrollment Database (NED), tools

that support enrollment processes, is

available at http://www.tricare.osd.mil/

pmo/programs/programs_main.html.

Business rules for enterprise-wide

assignment and toolkits to assist with the

PCMBN assignment process and provide

resources for the transition to primary

care management are available from

Regional Lead Agent offices.

Health Evaluation Assessment Health Evaluation Assessment

Review (HEAR) Review (HEAR) Review (HEAR) is a survey designed to

support MTFs in assessing the population

and in forecasting the demand for

required health care and resources. HEAR

implementation and usage varies across

regions and MTFs, and is generally

associated with the enrollment process

and Managed Care Support Contractor.

OASD(HA) Policy 97-003, Policy for

TRICARE Health Enrollment Assessment

Review Survey (http://tricare/policy/fy97/

hear9703.html), mandates use of the

HEAR as the TRICARE Prime health

assessment tool.

Population Health Operational Population Health Operational

Tracking and Optimization

(PHOTO) (PHOTO) supports the measurements

identified by the Tri-Service metrics

working group to assess the progress of

the MHS toward achieving the end states

of the MHS Optimization Plan. The

metric categories include customers,

business, clinical, force protection and

health. While these metrics are aggregated to support all levels of the MHS

enterprise, specific focus is being placed

at the MTF and PCM level. The MHS has

acknowledged the role of the PCM as

pivotal because this is the level at which

change can occur and this is where

health care is truly managed. Although

some metrics are already developed

(Phase I) others are still being developed.

Phase I metrics are expected to be

released across the MHS by late 2001,

with Phases IIA and IIB to follow. More

information is available at http://

photo.tma.osd.mil. Access is password

protected and a password can be gained

via the Website.

Survey of Health Related Behaviors Survey of Health Related Behaviors:

This 1998 survey is the seventh in the

series of confidential, anonymous

standardized surveys which asks active

duty service members about various

health behaviors, including the use of

illegal drugs, alcohol, tobacco, and atrisk sexual behavior. The survey also

assesses selected national health status

goals from the Department of Health and

Human Services’ Healthy People 2000

objectives, the mental health status of the

force, and specific health concerns of

military women. More than 17,000

service members, randomly selected to

represent men and women in all pay

grades of the active force throughout the

world, completed the survey. More

information is available at http://

www.tricare.osd.mil/tricaresurveys/

surveys01.htm.

All-Region Server (ARS) Bridge All-Region Server (ARS) Bridge is a

powerful tool used to obtain summary

and detailed views of population, clinical,

and financial data from all MHS regions.

The ARS Bridge includes MTF and

purchased care data integrated with

eligibility and enrollment data. The ARS

Bridge is the source of data for the

Population Health Navigator (PHN).

There are several key populations to consider for targeting smoking reduction

interventions. Active duty personnel (AD) should be identified at the base and unit

levels. Military service members have higher overall rates of

smoking compared to national rates. Also, the potential impacts

of smoking on personal fitness and resistant to illness make

smoking a Force Health Protection issue. MTF enrollees may be

identified as a population targeted by smoking cessation programs

and programs to provide educational materials. Each PCM will

want to identify smokers among his or her assigned enrollees and target them for

individualized assistance with smoking cessation. The MTF may want to target

outreach efforts to beneficiaries in the catchment area who aren’t enrolled but who

are smokers. Children with asthma may live with smokers. Pregnant women can be

another identifiable and (often motivated) population to target.

The HEAR survey will identify smokers. All enrollees should complete a HEAR survey.

Also, it is standard of care to ask patients who present for care if they smoke and then

to counsel and assist smokers. Many other surveys and data systems have information on smoking status in populations.
38

Access to the ARS Bridge is limited, but

facilities will generally have from 1 to 6

personnel who have been granted access.

If you need more data than is provided

through the use of other tools and local

resources, you may want to contact a

person at your facility who has this

access. Information is available at http://

www.eids.ha.osd.mil.

Defense Medical Surveillance System

(DMSS): The DMSS is an executive

information system whose database

contains up-to-date and historical data

on diseases and medical events (e.g.

hospitalizations, ambulatory visits,

reportable diseases, and health risk

appraisals) and longitudinal data on

personnel and deployments. It is

operated by the Army Medical Surveillance Activity (AMSA). AMSA publishes

the Medical Surveillance Monthly

Report (MSMR) which contains summary reports of notifiable diseases, trends

of illness of special surveillance interest,

and field reports describing outbreaks

and cases occurrences. Information

about DMSS is available at http://

www.amsa.army.mil.

Service-Specific T Service-Specific Tools:

Navy personnel should contact NMIMC

regarding the Population Health Navigator (CDR Mark Turner at

mailto:mdturner@us.med.navy.mil).

Air Force enrollment support information

is available at https://phsd.afms.mil/

PHSO/ (click on PCO).
39

Concepts

In the context of health care, a demand

forecast is defined as an estimate of the

volume of care (primary, secondary, and

tertiary prevention) required by a given

population. Demand is typically expressed in workload units. Examples of

such units include, but are not limited to,

number of visits by provider type, number

of mammograms required, number of

immunizations required, bed-days by bed

type, surgeries by type, and hospital

dispositions. Forecasting a population’s

demand is an essential component of the

process of improving that population’s

health. Each MTF and Region must

develop accurate demand forecasts that

establish the anticipated needs of the MHS

population, based on best clinical and

business practices, for Force Health

Protection, TRICARE, and MTF, worksite,

and community-based programs, at the

Region, catchment area, and facility

levels.

Demand forecasts are needed in order to:

 Ensure facilities are appropriately

sized to serve the population,

 Ensure facilities are adequately

staffed (in both numbers and mix of

providers and other personnel),

 Establish the need for special

activities such as immunization

programs.

 Ensure sufficient resources are

allocated to perform clinical

preventive services, provide health

promotion and education programs,

and conduct condition, disease and

case management programs

 Formulate managed care requests

for proposals and contracts,

 Formulate bid price adjustments,

 Establish budgetary documents such

as the medical Program Objective

Memorandum (POM)

Data that drive demand forecasting

include clinical preventive services

guidelines, prevalence of diseases and

injuries within a given population,

clinical practices used to treat a given

disease, and the system or operationally

defined required care. Demand forecasts

are singularly important as input for

determining the gap relative to the

capacity of a medical treatment facility to

provide health care. Forecasts are also

fundamental to establishing realistic

methods of calculating system costs, such

as capitation rates. It is critical that the

data that supply demand forecasts be

accurate to assure that facility sizing and

staffing decisions are appropriate,

resulting in maximal value i.e., optimal

quality with highest possible efficiency.

The management of a populationfocused health care system, especially in

an environment of constrained resources,

is complex. The tools required to make

resource decisions must recognize the

health status of the population and the

appropriateness of the clinical and

administrative decisions used to provide

health services to that population. In

economic terms, it is critical to understand and manage the production

function. The simple production

function outlined below hints at the

complexity of the problem:

This model states that a given population

generates a level of illness and injuries or

a need for interventions to prevent illness

and injuries, and that there are inherent

operational health care requirements in

the military. These platforms drive health

care resource requirements either at the

MTF or within the Managed Care

Network. To know how many resources to

provide to an MTF, ward or clinic, or to

accurately negotiate the best value

capitation rate in the MCSC, management must have some understanding of

the anticipated needs for health care

resources. Forecasting the demand for

health care is the first step in the active

management of resources.

Processes

System-Based Processes: System-Based Processes: Data on

population demographics, pre-existing

health conditions and chronic diseases,

health risk behaviors, past medical

history, and the perception of health

status will forecast the demand in the

population for direct care services along

high volume, high cost, and high risk,

problematic disease states. To forecast the

demand for health care

resources to meet

operational needs (e.g.,

pre-deployment

requirements), MTFs

must again have an

accurate profile of the

active duty and reserve

Forecast Demand

Population

Demand for:

Primary,

Secondary, Tertiary

Prevention

Programs

Unique Operational

Programs

Episodes of Care Resources
40

population. An additional data requirement is the anticipated/actual deployment schedule for the MTF population.

Consumer Consumer-Focused Forecasting -Focused Forecasting

Processes: Processes: Accurate demand forecasting

is critically dependent on accurate

population identification. Following the

model outlined in this MHS PHI Plan

(integrating the population data from the

first step, identification of population and

enrollment), an MTF will get an accurate

profile of the population eligible for care.

To forecast demand the following data, at

a minimum, must be retrieved:

 Defense Eligibility Enrollment

Review System (DEERS) population

profile by:

1. Health plan or program (Prime,

Extra, Standard, Medicare)

2. Beneficiary location

3. Provider location

4. Age and gender

 HEAR Survey data

1. Past medical history and pre-existing

and chronic diseases

2. Marital Status

3. Education level

4. Perceived health status

5. Health risk behaviors

 Location-specific (e.g., regional)

prevalence of conditions, diseases,

injuries, and risk factors, and

 Deployment information and status

of personnel

A common method for forecasting

demand in the health system is to use

historical utilization data. Utilization

data are easily obtained from within the

MTF and from normative utilization rates

for the community or for comparable

MTFs. There are limitations when using

historical data and normative data. The

utility of historical data is limited by the

necessary assumption that past utilization of health services was appropriate.

In other words, using historical utilization tends to reinforce the status quo

rather than the transition to a preventionbased health system. Normative data are

limited because there are population

differences within the community and

norms may not be applicable to a specific

MTF (Rohrer 1999).

The results of demand forecasting by

individual MTFs will be submitted and

coordinated at the Regional Lead Agent

offices and relevant Service intermediate

commands. It is crucial that these offices

work together to conduct regional

forecasts and address the demands on the

military direct care system and the

resultant impact on the Managed Care

Support Contract. The regional forecasts

will be used by the Services in developing

the appropriate funding and staffing

levels based upon the demand for

services.

Roles

Military T Military Treatment Facilities reatment Facilities have the

primary responsible for forecasting

demand. There are easy-to-use tools

available to assist in the forecasting effort

(see below). The MHS Optimization

and Population Health Support and Population Health Support

Center (OPHSC) Center (OPHSC) will be able to assist in

this endeavor. Regional Lead Agents Regional Lead Agents

Encounter Coding

Diagnostic and procedure codes constitute the language of reimbursement for

clinical care in health care. While MTFs use this same language to bill private

insurance, the information captured by coding MTF and contractor-provided

services is perhaps equally important for population health improvement processes. Diagnostic codes (International Classification of Diseases [ICD]) and

procedure codes (Current Procedural Terminology [CPT], and evaluation and

management [E&M]) generated and captured for each encounter provide a wealth

of useful information about the types of diseases and injuries in a population and

the types of services provided to meet demand. Coding data are used extensively to

forecast demand and manage capacity. Similarly, by analyzing the history of

services provided, reports can be generated to proactively identify individuals who

are due for preventive services or who are potential targets for worksite, community-based, and disease management programs.

Tools such as the Ambulatory Data System (ADS), and eventually CHCS II, support

MTF clinic teams in coding of encounters. Because of the importance of proper

coding to population health, MHS personnel need to be adept with coding tools

and processes. One tool is the encounter “superbill” which allows clinic support

staff to enter ICD, CPT, and E&M codes into information systems, thereby freeing

providers to spend more time with patients.

Coding templates, superbills and toolkits can be found by clicking programs/tools

at https://phsd.afms.mil/PHSO/. More information about ADS is available at

http://citpo.ha.osd.mil/index.htm and http://imcenter.med.navy.mil/ads (Navy).
41

and Service intermediate commands Service intermediate commands

are responsible for aggregating demand

information by geographic region or

functional area. They have the primary

responsibility for using information

about local health services demand to

distribute resources among MTFs and the

Managed Care Support Contractors in

their jurisdictions.

Tools

Health Evaluation Assessment Health Evaluation Assessment

Review (HEAR) Review (HEAR is a survey tool designed

to support MTFs in identifying the

population and in forecasting the

demand for required health care and

resources. HEAR implementation and

usage varies across regions and MTFs,

and is generally associated with the

enrollment process and MCSC. The role

of the MCSC in the HEAR process is

expected to decrease and that of the MTF

to increase when the HEAR program is

revised.

Utilization Review (UR) processes (UR)

have been extremely useful for demand

forecasting. Utilization Review provides

historical utilization information that

will continue to play a significant role in

how organizations analyze and forecast

demand. Guidelines for utilization

management and utilization review are

in the OASD (HA) Policy: Revised

Utilization Management Policy for the

Direct Care System (http://

tricare.osd.mil/policy/fy98/

umpd9831.html).

Air Force forecasting tool: Air Force forecasting tool: The Air

Force has developed tools to forecast

demand for clinical preventive services for

defined populations. Information is

available at https://phsd.afms.mil/PHSO/.

Navy Population Health Navigator Navy Population Health Navigator: Navy Population Health Navigator

A CD-ROM database created by NMIMC to

provide Navy MTFs with population-based

analysis capabilities. The tool enables

MTFs or clinics to describe the demographics, needs, and health status of the

enrolled and not-enrolled population,

and to manage medical and disease

conditions. For more information

contact CDR Turner at

mailto:mdturner@us.med.navy.mil.

Demand Forecasting Models Demand Forecasting Models: Demand Forecasting Models

Information from historical utilization of

medical services by the population

provides some indication of future

demand. However, future demand can be

expected to deviate from past demand for

a number of reasons:

 The population might be changing

in size (e.g., via homeport reassignments, active duty unit-level

movements, or active duty reduction

in force programs).

 The population might be changing

in composition (e.g., it might be

aging).

 Eligibility rules might be changing

(e.g., via Medicare subvention and

TRICARE For Life).

 Clinical practice might be changing

(e.g., via adoption of disease

management practices).

 Changes in enrollment and reimbursement strategies might cause

changes in access to care (e.g., via

changes in deductibles and copayments).

 Changes in market areas might

cause changes in access to care (e.g.,

via creation of Centers of Excellence).

 Technological changes might be

increasing access to care (e.g., via

telemedicine) or improving the

efficiency or quality of care (e.g.,

through introduction of new

diagnostic equipment).

 Operational requirements for FHP

might change (e.g., pre-deployment

requirements).

Methods are therefore needed to project

future demand in the context of a

changing environment, changing clinical

capabilities, and changing clinical and

business practices. Expert judgment

provides one potential means for

estimating changes in the demand for

care in a changing world. However,

human beings have limited ability to

synthesize the effects of changes in the

inputs to a complex process (such as

health care delivery) on the outputs of the

process. Mathematical models such as

simulations, econometric models, and

other analytic tools provide a means to

assist experts and decision-makers in

such synthesis. Models can synthesize

information about factors such as

population size and demographics,

incidence and prevalence of disease,

wellness programs, screening programs,

medical readiness requirements, access to

medical care, clinical protocols, provider

efficiency, substitutability of providers,

and equipment capabilities to predict the

demand for medical resources.
42

Figure 11 is a simplified illustration of a

model-based approach to forecasting

demand. The process begins by developing a projection of the sizes of future

beneficiary and

enrolled populations. Historical

utilization rates

(such as average

per-capita

numbers of visits

and bed-days) by

each demographic group in

this population

(grouped by age,

gender, beneficiary category, etc.) are then

established. These historical

rates are modified to account

for the effects of changes in clinical

capabilities and clinical and business

practices. Application of these utilization

rates to the population results in an

estimate of future demand.

The Managed Care Forecasting and

Analysis System (MCFAS) is a decision AS)

support system that supports this

modeling process, while accounting for

many complexities of the MHS that are

not addressed in this simplified depiction

of the process. MCFAS is developed and

maintained by the Corporate

Executive Information System Program

Management Office (http://

www.eids.ha.osd.mil).

Healthcare Complex Model Healthcare Complex Model (HCM):

HCM describes the workload requirements

and performance characteristics of the

virtual health care system under alternative assumptions about resource allocation, technology integration, workload,

and case mix. As a simulation model,

HCM offers the kind of flexibility to

experiment unavailable in other models

but it does not determine an optimal

solution. Rather, the user will seek a

”good” solution by examining and

comparing multiple cases. The

Healthcare Complex Model is designed to

be used at the Region level and is

currently being tested. For information

about this tool contact a representative at

http://www.tricare.osd.mil/opt_int/

PHIT_Member.htm.

Using health assessment data and other data on the prevalence of smoking in

various MTF populations, forecasts of the demand for smoking reduction programs

can be accomplished. In addition, historical data can help with

forecasting the demand for services needed to address smoking.

For example, attendance rates at smoking cessation programs, the

usage rates for nicotine replacement and other appropriate

therapies, and the diagnostic and therapeutic services needed to

treat smoking-related illness all contribute to demand forecasting

at the MTF. Formal demand modeling tools incorporate smoking data to create

sophisticated models of future demand. These models consider changing trends in

smoking, effectiveness of interventions, and other assumptions in building detailed

demand forecasts.

The worldwide burden of smoking related illnesses is growing. Smoking rates are

increasing among youth in the U.S. and among all ages in developing countries.

This burden will result in a demand for health resources that is far greater than

historical levels (Fielding, Husten and Eriksen 1998).

References

Fielding, JE, CG Husten and MP Eriksen.

1998. Tobacco: health effects and control.

In Public Health and Preventive

Medicine. ed. RB Wallace.

Samford, CT: Appleton and

Lange.

Rohrer, JE. 1999. Planning

for Community-Oriented

Health Systems. Washington, DC: American Public

Health Association. Apply

Utilization

Rates to

Population

Establish

Utilization

Rates

Identify

Changes

in

Utilization

Rates

Project

Population

&

Enrollment

Demand

Figure 11. Summary of model-based demand Figure 11. Summary of model-based demand

forecasting forecasting
43

Concepts

Demand management is a collection of

proactive interventions focused on

reducing unnecessary health care

utilization while simultaneously encouraging the appropriate use of health care

resources. Demand management reflects

the activities of a health system designed

to create a healthy environment, decrease

morbidity and mortality, and encourage

the use of effective decision-support and

self-management tools; thus, enabling

beneficiaries to use health care resources

appropriately. Use of demand management strategies will decrease the need for

urgent, episodic care. Its ultimate goal is

to manage the health of individuals and

populations with a focus on prevention of

illness and injury. It includes primary

prevention services for healthy people and

secondary prevention services for

individuals who already have early

disease. Some prefer to call this combination of interventions demand improvement.

There are several components to a

comprehensive demand management

strategy. Some components are:

 Assess, monitor and encourage the

demand for primary, secondary, and

tertiary prevention services in the

population.

 Reduce the use of unnecessary or

marginally effective health care.

 Reduce and, where possible,

eliminate environmental conditions

and lifestyle behaviors contributing

to morbidity (health protection and

health promotion)

 Reduce temporary and permanent

disability and impairment associated

with symptoms, clinical conditions,

diseases or injuries.

 Eliminate delays in seeking medical

advice where appropriate.

 Monitor the health of the beneficiaries through a comprehensive

surveillance system.

 Engage non-medical leadership in

community health efforts.

Processes

Individual, Consumer Individual, Consumer-Focused

Processes: Processes: Demand management

strategies begin as the beneficiary is

enrolling into the system and continue

throughout the enrollment addressing

current and anticipated future health care

needs. During the enrollment process, a

timely, thorough assessment of the

enrollee’s subjective (self-reported) and

objective (enrollee’s medical record)

health needs will be completed. This data

will be reviewed by a health care professional with the enrollee, addressing

individual and family issues. An

individual health improvement plan is

then developed by the health care

provider/provider team and enrollee and

implemented throughout the enrollment

period. The specific processes are:

 Promptly enroll and assign enrollees

to PCMs (see Identify the Population). These initial steps are

important for developing a relationship between enrollees and the

health system.

 Distribute HEAR Survey to active duty

and individual family members.

Primary care team member will

review information and discuss

findings with the individual.

 Educate beneficiaries about primary

care triage systems and self-care

programs (such as nurse triage,

advice lines, health information

lines, web-based approaches and

age-specific self care books).

 Utilize patient-based preventive care

tools; shared decision-making

programs; practice guidelines; the

Put Prevention Into Practice (PPIP)

initiative; and Preventive Health Care

Application (PHCA) or similar

computer-based tool.

 Establish a central access point to

ensure beneficiaries have access to

advice and appropriate care through

phone or in-person (sometimes

called telemanagement)

 Establish a surveillance system for

tracking the health status of

individuals overall and during

deployment.

Pre-deployment, deployment and postdeployment health issues need to be

integrated into the active duty member’s

medical record and reviewed by the

health care provider at redeployment. A

seamless system of health services

between garrison and deployment is

critical. Several directives mandate

surveillance:

 Guidance mandate: Public Law 105-

85; states “The Secretary of Defense

shall establish a system to assess the

medical condition of members of the

armed forces ... who are deployed

outside the United States or its

territories or possessions as part of a

contingency operation (including an

humanitarian operation, peacekeeping operation or similar operation)

or combat operations.” This is

accomplished through the DoD

Prevention Council

 Assistant Secretary of Defense of

Health Affairs (ASD-HA) Policy for

Pre and Post Deployment Health

Assessments and Blood Samples,

Manage Demand
44

dated 6 Oct 1998

 Joint Chiefs of Staff Memorandum, 4

December 1998, “Deployment Health

Surveillance and Readiness”

 DODD 6490.2 “Joint Medical

Surveillance,” 30 August 1997

 DODI 6490.3, “Implementation and

Application of Joint Medical Surveillance for Deployments,” 7 August

1997

Population/System Processes: Population/System Processes:

Population health includes populationspecific health needs, which must be

addressed by worksite and communitybased interventions as well as by practitioner interventions in the MTF. Populations could consist of a provider’s

patients, or active duty members assigned

to specific units, not just patients with a

common condition. When populations

also have a common community,

demand-management strategies need to

be oriented to the needs of the population

within that community environment.

Strategies might include activities such as

limiting places where people can smoke,

limiting access to tobacco products,

creating facilities for exercise, creating a

variety of opportunities for mental and

spiritual health enhancement, and

ensuring recreation activities conducive

to healthy lifestyle. Such efforts require

the involvement of community leaders

and health professionals (see Community

Outreach).

Key Implementation Processes: Key Implementation Processes:

a. Train and educate staff

§ Train all levels of clinical staff

on available resources for support (i.e.,

clinical practice guidelines, web-sites,

self-care manuals, and posters) and their

roles in managing demand. Supplies can

be ordered through AHCPR Publications

Clearinghouse, P.O. Box 8547, Silver

Spring, MD 20907 or http://

www.ahcpr.gov/ppip/pporder.htm.

 Primary focus is to change the

culture to incorporate education on

prevention into every opportunity;

(e.g., clinic visits, school curricula,

commissary events, health fairs, and

media events).

b. Utilize data from a variety of sources

to establish population trends and

target priority training programs

(see Analyze Performance and

Health Status)

c. Maximize appointment efficiency

 Assess allocated appointment time

and beneficiary check-in processes in

order to maximize opportunities to

implement PPIP components (for

example, prevention training of

beneficiaries by medical aides, review

of family profiles by nurses, etc.).

 Coordinate efforts among staff to

provide a multidisciplinary approach

for screening medical record

information to ensure requirements

of PPIP are met and to maximize

appointment efficiency.

d. Document health information

 Before, during, and after deployments, record all health interventions (e.g., immunizations, exposures, etc.) for the individual or unit

in the individual’s medical record.

Roles

The entire health team is responsible to

manage demand. The personnel

responsible for the many components of

demand management are identified in

the processes described above.

Tools for the Continuum of

Demand Management

Initial Health Assessment Using the Initial Health Assessment Using the

Health Evaluation Assessment Health Evaluation Assessment

Review (HEAR): Review (HEAR): It is critical to ensure

that all beneficiaries are enrolled in a

timely manner. The enrollee databases

between the MTF, contractor, and local

base personnel administration offices

(Personnel Support Detachment (PSD),

Out-processing Site, etc.) need to be

thoroughly integrated and coordinated to

enhance enrollment and survey completion.

The initial health assessment tool is the

HEAR. [Guidance mandated: DoD (HA)

Policy 97-003, https://

www.tricare.osd.mil./policy/fy97/

hear9703.html]. This is an age-appropriate survey distributed to all TRICARE

PRIME (including active duty) beneficiaries by the TRICARE Contractor when the

member enrolls. Age-appropriate selfcare books are distributed with the HEAR.

The Self-Reporting Tools Working Group,

a subcommittee of the Prevention, Safety

and Health Promotion Council, serves as

a reference source for issues pertaining to

the successful deployment of the HEAR.

The HEAR survey is available as a PCbased automated tool. It will eventually

be incorporated into Composite Health

Care System II (CHCS II).

The HEAR summary report for each

individual should be distributed by the

contractor to the MTF, and with the

enrollee’s medical record, should be

analyzed by an enrollment “team”.

Under the concept of “PCM by name” the
45

beneficiary is enrolled to a specific health

care provider based on identified health

care needs. The provider then develops a

health improvement plan for the

individual. A member of the health care

team meets with the enrollee, discusses

the data and proposed health improvement plan, and finalizes the plan with

input from the enrollee. During this

meeting, the team member provides

information to the enrollee on; the selfcare book, identification of potential

behavioral, lifestyle, environmental risk

reduction and health care needs pertinent

to that individual; and other system “demand management” tools such as the

Health Care Information Line (addressed

below). The responsible health care

provider, for purposes of efficiency, may

delegate the initial health improvement

plan to another team member. However,

oversight and an early face-to-face

introduction with the health care provider

are necessary. These interventions with

individuals to review findings provide a

key opportunity to initiate care, provide

clinical education, and to introduce the

enrollee to the health care system and its

capabilities. No HEAR summary report

will be placed in an individual’s medical

record until reviewed by an authorized

medical staff member.

In addition, the contractor, if distributing

the HEAR, can provide a summary

population profile on non-MTF enrollees

who reside on the installation. These

population profiles can be used as a basis

for discussions at Installation Population

Health Council meetings to address

community needs.
46

Primary care triage systems and

self-care programs: self-care programs:

a. A comprehensive system

of advice lines, health

information lines, webbased approaches and

self-care books, and

educational interventions

will enhance demand

management. (Guidance

mandate: SECNAVINST

6100.5, OPNAVINST

6110.1D, SECNAVINST

5100.13A, DoD Directive

1010.10)

b. Ideally, a patient will have a

single point of contact for care access

and management. For the near future

a central access number will be

provided with a minimum of three

access options:

§ Health Care Information Line.

The TRICARE contractor is responsible

for implementing and maintaining

Health Care Information Lines (HCIL)

24 hours a day to provide guidance to

beneficiaries. Guidance includes selfcare options and/or sources for health

care services. [DoD (HA) Policy 97-049,

http://www.tricare.osd.mil/policy/fy97/

hcil9749.html, provides guidance

regarding documentation of HCIL

information forms in patient medical

records.]

§ Triage health care professional. A triage health care professional

can assess a patient’s condition based

on approved protocols and refer the

patient as appropriate (to appointment

section, to emergency department, to

HCIL, etc.) He/she should have access

to patients’ medical records for review

of patient health conditions and enrollment information. He/she should also

have immediate access to a PCM for

consultation.

 Message center for PCM. To leave a

message for the PCM or PCM’s team.

c. It is important to have early

health care intervention to

decrease the probability of

a condition worsening as

well as to monitor for

appropriate system usage.

The access system should

have computerized ability

to track the incidence of

patient calls by name or

social security number,

reason for call and referral

option provided (HCIL,

triage, appointment,

message). It should be

able to aggregate demand

data for specific threshold

levels. For example, based

on clinical protocols, it

would be able to aggregate

Smoking presents an excellent example for how demand management activities can

be employed and of their impact. The initial health assessment for each enrollee

should identify smokers. Smokers and non-smokers at risk for

initiating smoking (e.g., adolescents) can be advised and assisted

when they first meet with their PCM to discuss their personal

health plans. This leverages the power of demand management

that comes from intervening before disease occurs or progresses.

PPIP tools helps remind members of the clinic team to ask about

smoking and take appropriate action when smokers are identified. Worksite and

community-based programs provide education and counseling to reduce smoking,

thereby contributing to demand management. There is strong evidence that

smokers at all ages use more health care services than non-smokers and that

demand for health services decreases promptly after smokers quit.

The imperative is strong for intervening in the number one preventable cause of

premature morbidity and mortality to improve demand for health services. Primary

prevention of smoking initiation should be a priority demand management and

population health improvement strategy.

data for patients who are

over 60 years old making

more than 4 calls in a

month due to respiratoryassociated illnesses. Once

threshold levels are

reached, an automatic

referral to the case

manager should be

generated; the case

manager should contact

the patient for further

evaluation within 48 hours

of the last call. In addition,

the system should track

types of calls by geographic

location or other population group determination

(for example by troop

units). Summary data on

population usage should be

reviewed by the case

manager and referred to

clinic and MTF planners.

Put Prevention into Practice (PPIP) Put Prevention into Practice (PPIP):

[Guidance mandate: DoD (HA) Policy 98-
47

027, 31 Mar 98, http://

www.tricare.osd.mil/policy/fy98/

ppip9827.html]. PPIP is a national

campaign developed by the Office for

Disease Prevention and Health Promotion, Department of Health and Human

Services, to improve the delivery of

clinical

preventive services in primary care

settings. It is a comprehensive approach

targeting health promotion and disease

prevention throughout the life cycle, and

thus a critical demand management

approach.

Oversight responsibility for implementation by each service:

 Navy – Naval Environmental Health

Center (NEHC),

http://www-nehc.med.navy.mil/hp/ppip

Army – Center for Health Promotion and

Preventive Medicine (CHPPM),

http://chppm-www.apgea.army.mil/.

Air Force – Population Health Support

Division (PHSD), see programs/tools at

 https://phsd.afms.mil/PHSO/.

Preventive Health Care Application

(PHCA) (Guidance mandate: None.

http://www.tmssc.brooks.af.mil/TMSSC/

PHCA, or http://

www.nmimc.med.navy.mil/phca, or

https://phsd.afms.mil/PHSO/) is a

comprehensive system for addressing the

on-going health care needs of enrollees

and is a critical element to a thorough

demand management program. Systems

such as PHCA and CHCS II will prove

helpful for tracking the health status of

individuals and populations. Information about CHCS II is available at http://

citpo.ha.osd.mil/projects/chcsii/chcsiimain.htm.

The PHCA is a Tri-Service Medical

Systems Support Center (TMSSC) tool

that enables the clinician to deliver and

track appropriate and timely preventive

services for all enrolled military members. Additionally, clinical and management staff can use PHCA to retrieve,

maintain, manipulate, and analyze

clinical data, and to display and print

timely, accurate, and accountable clinical

preventive services and immunization

reports.

PHCA was developed to automate the

PPIP program through the integration of

HEAR 2.0, CHCS information, and

immunization data from the Immunization Tracking Module (ITM). A phased

implementation schedule was initiated in

March 1999 but will not proceed to all

MTFs as PHCA will be replaced by CHCS

II. Limitations of the current program

are being addressed at various levels;

however, support for the system will

continue until it is subsumed by the

automated HEAR or CHCS II.

The Air Force Population Health Air Force Population Health

Data CD provides MTFs and PCMs with

quarterly reports of performance in

delivering needed clinical preventives

services. The reports identify enrollees

who have not had recommended

preventive services and provides contact

information (see Data info at https://

phsd.afms.mil/PHSO/). This information

is accessible only to those providers and

managers to whom enrollees are

enrolled.

Navy Population Health Navigator Navy Population Health Navigator: Navy Population Health Navigator

A CD-ROM database created by NMIMC to

provide Navy MTFs with population-based

analysis capabilities. The tool enables

MTFs or clinics to describe the demographics, needs, and health status of the

enrolled and not-enrolled population,

and to manage medical and disease

conditions. For more information

contact CDR Turner at

mailto:mdturner@us.med.navy.mil.

Periodic Health Assessment Using the Periodic Health Assessment Using the

HEAR: The HEAR survey can be repeated

periodically as a surveillance activity.
48
49

Concepts

To manage capacity is to optimally

match the quantity and quality of

interventional (individual) and prevention (population-based) health services

provided by the MTF with the appropriate

demand of the population. Random

House defines capacity as 1) the ability to

receive or contain; 2) volume; 3) actual

or potential ability to do something. The

challenge facing the MTF is to link the

management of workload (i.e., population demand and clinical practice) to the

management of the capacity (i.e.,

funding, staffing, facilities, and equipment) necessary to meet that workload.

This link is critical because capacity

decisions directly influence cost and

access. Resource management tools

allow leaders to understand the resource

implications of decisions related to

demand, clinical practice, and capacity.

In addition, MTF capacity must be linked

to best clinical and business practices.

Improving clinical and business outcomes depends on active management of

patient volume, clinical practice, facility

size, and staffing. A detailed discussion of

health services management principles,

practices, and tools is beyond the scope of

this plan and guide. Some of the salient

facets of capacity management in the

context of population health activities at

the MTF are outlined below.

Processes

Capacity optimization in the MHS can

occur through two strategies: 1) reduce

the excess capacity of the direct care

system where appropriate, or 2) increase

throughput of the direct care system, thus

reducing dependence on the managed

care contractor. Managing capacity is the

key to meeting access and resource goals.

Consumer Consumer-Focused Processes: -Focused Processes:

• Forecast population demand for

direct care system and operationally

required health care

• Employ demand management

strategies

System-Based Processes: System-Based Processes:

• Identify gaps between forecasted

needs and health service capacity

and develop strategies to close gaps

• Establish explicit performance

targets

• Resource MTFs based on best clinical

and business practices to meet

population needs

• Practice evidence-based care (do the

right thing)

• Improve efficiency (do things right)

Military T Military Treatment Facility Enroll- reatment Facility Enrollment Capacity Factors: ment Capacity Factors: The capacity

of an MTF to enroll its beneficiaries is

affected by many factors, the primary one

being the numbers of PCMs that are

available at that MTF. A review of civilian

literature and work done within the

Services suggests that a reasonable goal

within the MHS is 1500 enrollees per

PCM. To accomplish this goal requires

reengineering of our primary care clinics.

The PCM ratio depends primarily on four

factors: demand, productivity, availability,

and readiness considerations, and each of

these factors needs to be managed to

produce optimal results in terms of

quality, access and cost. Quite simply, to

reach 1500 enrollees per PCM will require

significant reductions in the average

number of primary care visits per enrollee

through the use of nurse advice lines and

nurse triage systems, self-care books and

pamphlets and prevention measures (i.e.,

demand management strategies). It will

require greater productivity using

appropriate support staff, examination

rooms, scheduling techniques, and

practice patterns. It will also require the

availability of assigned PCMs and

dedicated support staff to staff primary

care clinics for the vast majority of their

work week. Primary care team members

should be available in their clinics at

least 75% of their duty time. Finally, it

will have to be balanced by the unique

demands that are incurred by the MHS

readiness mission.

Military T Military Treatment Facility reatment Facility

Throughput Capacity Factors: Throughput Capacity Factors:

Primary care efficiencies are not accomplished in isolation from other services

performed at an MTF. Subspecialty care,

ancillary services and administrative

functions must also assimilate the

concepts of population health as the

paradigm for the entire system. Those

resources that can be utilized to off-load

the demand of critical bottlenecks must

be employed to alleviate the stress on the

critical rate limiting resource within the

MTF.

Roles

The detailed work of aligning the right

quantity and quality of resources to the

appropriate demand by the population is

the responsibility of mid-level clinic

managers and resource managers, under

the direction of clinic and MTF leaders.

The tasks can be technically intense

requiring MTFs to have capabilities in

budget analysis, personnel and manpower, logistics, and facilities management.

Tools

A substantial portion of MHS expenditures

is fixed in staffing, facilities, and equipment. The active management of this

Manage Capacity
50

fixed capacity is complex and requires

decision support tools that allow managers to understand the ramifications of

decisions they make. These tools must do

the following:

• Analyze the complexities of disease

management product-lines and the

practice of evidence-based medicine

• Support “best” practices over the

status quo

• Empower the clinical leadership

• Effectively conduct business case

analyses

The decision support tools necessary will

come from the fields of industrial

engineering and operations research. At

the MTF they are likely to include:

simulation, survey analysis, descriptive

statistics, and tests of statistical significance. Decision support tools such as

these allow strategic goals to be linked to

operational processes.

The Template Analysis T emplate Analysis Tool (TAT) is a

powerful tool to help MTFs manage

appointments prospectively and to ensure

capacity is used efficiently and effectively.

See http://www.tricare.osd.mil/tools.

Business planning tools Business planning tools are available

at https://bumed.med.navy.mil/med03/

tools/default.asp (Navy) and https://

phsd.afms.mil/PHSO/ (Air Force).

Primary Care Management:

The Keystone of Capacity

Management

Integrating Concepts, Processes, Roles

and Tools for PHI

High quality primary care is one of the

principal foundations for population

health improvement. At the same time,

health policy choices around primary

care are often framed as “either-or”

propositions such as “Do patients value

primary care, or do they value specialty

care?” The answer for most is that they

value both! The challenge for the MHS is

to create a practice environment that

promotes and fosters the beneficiaryprimary care team relationship. This is

the objective for the Services’ initiatives in

primary care reengineering and

primary care optimization (PCO). The

primary care team is not only a member

of the MTF health care team, but has a

central leadership role. The primary care

team must have the appropriate amount

and degree of clinical support and a

personal “ownership and investment” in

the relationship. As such, essential

elements of primary care include the

following:

 Accessibility and accountability (with

the first-contact point of entry into

the MHS),

 Continuity of care (with established

patient loyalty and excellence in

service),

 Comprehensiveness of care (with the

right mix of PCM and other staff),

 Coordination of referrals (both

inside the Direct Care System and in

the MCS Network),

 Understanding of demand management objectives (and timely access to

triage services), and

 Understanding the member, military

family and community’s expectations for “health”

Components of Primary Care Components of Primary Care

The desirable features of primary care

include:

1. First contact: Primary care is

frequently perceived as the point of

first contact with the MHS. This

could involve an assessment by a

PCM or PCM team member at

separate MTFs. The key to the firstcontact process involves an adequate

evaluation, prioritized assessment

and therapeutic plan initiated by the

Open Access Appointing

One innovation that is gaining substantial favorable attention is open access

appointing of primary care visits. Open access appointing is a practice wherein

patients are seen the same day that they call for an appointment, regardless of the

nature of their care needs. Clinics keep the majority of appointments available to

be booked for same-day visits. A small percentage of appointments are booked in

advance to accommodate patients’ desires to schedule in advance. The principle

driving the move to open access is that it is most efficient and satisfying to “do

today’s work today” (Murray and Tantau 2000).

There is a challenging transition period in getting to an open access practice but

patients, providers, and clinic staff report increased satisfaction once their clinic

has achieved open access. Patients get care when they need it and when they want

it. Clinic providers and staff spend much less energy juggling issues such as

patient care priorities and resultant complaints and frustrations.

There are many variations in how to implement open access. Some MTFs have

transitioned to open access and are enjoying the many benefits.
51

PCM team in a manner where

patient-level data are documented

and appropriate access to additional

providers is readily achieved. In the

civilian sector, it is estimated that

annually 75-85% of individuals

require only primary care services.

In other words, referrals to secondary

care settings or short-term consultations account for only 10-15% of

patient services, and referral to

tertiary-care settings only 5-10%

annually.

2. Continuous or longitudinal care:

The second important component of

primary care is that of the continuity

of ongoing care, that is, personfocused care over a period of time.

3. Comprehensiveness requires that the

primary care provider offer a range

of services broad enough to meet all

the common needs in the population.

4. Coordination of health care services

requires an information system that

contains all of the patients’ relevant

health care data. At present, a

referral is frequently made by means

of hard copies documents, but the

speed at which information and data

processing is done today would

indicate a need for restructuring.

Nevertheless, it is key for the provider

to be involved in the coordination

role.

5. Individual and familycentered strategy requires a

carefully constructed

infrastructure that supports

active duty members and

their families in both a

deployed and home-based

environment. With

increasingly higher degrees

of “op tempo,” strategies

are needed that provide best

use of time to meet

professional and personal

goals, both at work and at

home. This will yield a

more effective and healthy

Soldier, Sailor, Marine or

Airman. As with any large

civilian or military

organization attempting to

deliver state-of-the-art

health care, patient

satisfaction is frequently

proportional to the

effectiveness and personal

nature of the last patient

encounter. In meeting the

community’s needs

through a populationfocused health care system,

the degree to which “all

health care is personal”

must not be diluted by the

need to standardize.

6. Community-orientation:

The natural extension of a

family-centered health care

approach must reflect the

unique opportunities,

challenges, and resources

offered to members of the

larger community of Army,

Navy, Air Force or Marine

Corps.

7. Accountability: Finally to

be addressed in more detail

is the issue of accountability by both beneficiary and

provider.

Expectations and Responsibilities of the

Beneficiary, PCM and Clinic Staff

Responsibilities of beneficiaries enrolling

in TRICARE Prime, PCMs and clinical

staff must be communicated adequately

and must include at a minimum:

Beneficiaries: Beneficiaries:

 Responsibilities to understand

processes and comply with requirements governing access and

referrals.

 Responsibility to assist the PCM and

other clinical staff by completing

HEAR forms, using demand management services, and limiting use of

Emergency Medical Services when

more appropriate primary care

activities are available.

 Responsibility to care for oneself and

develop a healthy lifestyle.

 Right to be treated respectfully, to be

listened to, and to have needs

addressed by competent and

compassionate professionals at all

levels, in clean and well-maintained

facilities.

Primary Care Managers (PCMs): Primary Care Managers (PCMs):

 Explain in simple terms TRICARE

benefits, the responsibilities of the

TRICARE system, and the rights and

responsibilities of beneficiaries

 Assure that the beneficiaries’ risks

and benefits are understood.

Primary care managers must assure

that beneficiaries who enroll in

TRICARE Prime understand the

procedures for getting care. They

must assure that the patient

understands these responsibilities,

and must provide adequate reference

materials.

 Ensure access to comprehensive
52

primary care services and other

enhanced benefits.

 Assure patients have access to PCMs

and demand management tools

twenty-four hours a day and that

clinics meet the appointment access

standards. Twenty-four hour access

means patients can reach a PCM or a

member of a pre-established team

familiar to them whenever they wish.

 Develop individual integrated

evaluation and treatment plans

based upon HEAR and clinical

assessments for empanelled patients.

 Reengineer clinics to foster enhanced

productivity by clarifying PCM team

roles and responsibilities.

Clinic Managers: Clinic Managers: Each MTF has the 

responsibility to identify the number of

PCMs they have employed. This would

include active duty and civil service

primary care physicians, PAs, NPs, as well

as providers who are under some form of

personal service contractual arrangement. A complete listing of fully trained

physicians within the MTF setting, branch

clinics, physicians in-training, and

providers who are part of an internal

partnership or resource sharing agreement must be maintained. The number

of enrolled beneficiaries distributed

among providers must also be kept up to

date.

Many management decisions can be

made once the number of potential PCMs

and beneficiaries is known:

1. How many PCMs are needed for the

number of beneficiaries enrolled in

TRICARE Prime,

2. How many PCMs would be required

to recapture beneficiaries using

TRICARE Standard,

3. What mix of providers constitutes the

pool of PCMs within a clinic,

4. How primary care services are

organized and what model best

serves the needs of the population,

5. Define the population-based needs of

the entire empanelled practice and

develop strategies to meet those

needs,

6. What percentage of time is committed from each provider who performs

Primary Care activities and what

percentage of full time equivalent

(FTE) activities is directed toward

specialty care, administrative or

operational activities, and

7. How best to utilize current and future

clinic designs to achieve efficiencies

of patient flow

Primary care clinical and administrative

support staff must be available in

sufficient numbers to optimize the time

that clinicians spend with patients.

Appropriate support staff should perform

functions before, during, and after

appointments that do not require the

unique capabilities of a provider.

Primary Care Ratios and Enrollment

Model

The number and mix of primary care

providers must satisfy demand and ensure

access to all necessary services. Ratios

will vary among Regions based on

enrollee demographics, epidemiologic

data and personnel resources. Adjustments should be made as appropriate.

Request for Proposal language in

TRICARE managed care support contracts specifies, “The PCM requirement is

a ratio of one PCM to every 1,500

enrollees.” One approach to determining

enrollment ratios for PCMs can be found

in the text box at the end of this section.

Variables that must be considered during

development of PCM panel sizes include:

 Professional competence, team

composition, patient case-mix, and

Having established the demand for primary, secondary, and tertiary prevention

strategies to address smoking and smoking related illness, the appropriate capacity

must be in place to meet the demand. It can be anticipated that

every MTF will want to provide printed and other materials to

support smoking prevention and cessation education. In addition,

they will need to either have a high quality smoking cessation

program or assure that beneficiaries can access programs in the

nearby community. Smokers must have access to PCMs and other

providers who are trained to provide counseling and to manage adjunct pharmacotherapy. Providers must be available to follow-up with smokers. Adequate numbers

of support staff capable of advising smokers are required as well. The MTF must

ensure the resources are available to provide nicotine replacement and other

medications used to both help smokers quit and treat smoking related illnesses.

Capacity is required to meet the demands for diagnosis and treatment for smokingrelated illnesses. MTFs need capacity to support worksite and community-based

smoking reduction programs and to serve on related base and community committees.
53

enrollee needs and preferences,

 Distribution of diseases and injuries

in the population and the frequency

with which these diseases and

injuries need to be encountered for

practitioners to maintain their

competence,

 Administrative, medical readiness,

and other military-unique demands

on providers,

 Calculation of “full-time equivalents” (FTEs) of primary care

providers ,

 Maintain a balance - high ratios

impact on provider practice patterns

(more referrals to specialists, for

example), staff morale, and patient

satisfaction; lower ratios may result

in decreased productivity and

financial risk to the organization,

 Support staff capabilities, and

 State law, professional practice acts

and standards of care.

Integrating Workplace Health in

Primary Care Primary Care

Traditionally, privileged providers in the

primary care setting have concentrated

on diagnosis and treatment of illness and

injuries. A comprehensive health care

plan, such as the PHI Plan, must include

health promotion and wellness, disease

and disability prevention, timely diagnosis, treatment, rehabilitation, counseling

and advocacy, all in support of “return to

function, return to work.” This issue

must be emphasized separately in any

new model to clearly identify to the Line

Commanders in particular and to

beneficiaries in general, that treatment is

not complete or successful until the

patient’s return to gainful employment or

to previous function has been accomplished.

Primary Care Education

It is clear that communication skills and

the response to patients’ needs are vital to

the current practice of medicine. Health

professions education must focus on

teaching practitioners how to form caring

relationships with their patients and their

communities.

Educational goals need to include the

acquisition of technical skills such as the

tools necessary to carry out practice-based

research, in addition to teaching health

care practitioners to evaluate their skills

and set goals for future improvement and

learning. By using worksite and community-based health care sites to carry out

needs assessments, conduct health

promotion and health education

programs, and to evaluate outcomes, an

ideal teaching and learning environment

is created.

Information about Air Force education

programs in epidemiology, primary care

optimization (PCO), and others is

available at https://phsd.afms.mil/PHSO/.

Army information: http://

www.cs.amedd.army.mil/AMEDDCS/

default.htm.

Navy information: https://

bumed.med.navy.mil/MED53.

Reference

Murray, M, and C Tantau. 2000. Sameday appointments: exploding the access

paradigm. Family Practice Management 7(8):45-50.
54

Estimating PCM Enrollment Rates

The capacity of a Military Treatment Facility (MTF) to enroll its beneficiaries is affected by many factors, the primary one

being the number of Primary Care Managers (PCMs) available at that MTF. Simply put, the number of enrollees that can be

enrolled to a PCM can be calculated by the following equation:

Enrollees/PCM = Enrollees/Visit X Visits/Hour X Hours/FTE X FTE/PCM

Enrollees/Visit: The higher the average number of visits, the fewer number of beneficiaries can be enrolled. To manage more

enrollees, demand for care needs to be managed. Nurse advice lines, self-help pamphlets, prevention measures, and limited

repeat visits are some of the tools used to reduce the visit rate. Historically, the MHS has had particularly high visit rates.

Some portion of these high rates is due to the intrinsic nature of the military; some portion is due to nature of the benefit that

for MTFs is free of co-payments; and some portion is simply due to the way in which the military counts visits. For the

purposes of this model, visits will only mean those seen in an ambulatory setting, not telephone consults or prescription refills.

For the most part, these will be appointed or acute visits that are seen for the equivalent of an appointment.

The true target for the visit rate will depend on multiple factors, including: age, sex and health status of the enrolled population, incidence/prevalence of disease, preventive care measures, monitoring and treatment of chronic diseases (such as

asthma or diabetes), practice patterns for follow-up appointments for acute illnesses (such as urinary tract infection), and

policies for referral to specialists. Current estimates for military visit rates to primary care range from 4 to 5 visits per enrollee

per year. Civilian estimates are from 3 to 4 primary care visits per person per year. Milliman and Roberts ambulatory criteria

suggest that the rate should not be higher than 3.2 visits per person per year.

Provider Visits/Hour: Historically, clinics within MTFs have had limited support staff and exam rooms relative to the number

of providers. As a result, the number of patients that could be seen in an hour was considerably fewer than optimal. Industry

norms report support staff ratios on the order of 3 to 3.5 support staff for each provider. Two to three exam rooms per provider

are not uncommon. These allow administrative and some clinical tasks to be done before the provider enters the exam room

and allow patients to be seen in overlapping blocks of time. Current estimates on the number of visits within MTFs are

significantly fewer than 3 per hour per PCM. On the other hand, PRIMUS clinics, with support staff ratios of 3:1 to 3.5:1,

typically handle 3.5 to 4 visits per hour. With the right support staff and rooms, PCMs should be able to schedule 3 to 4 visits

per hour.

Available Hours/FTE: The more inpatient or administrative responsibilities a provider has, the fewer number of hours can be

spent in the clinic seeing patients. This translates into a reduction in the number of beneficiaries that may be enrolled. Leave,

holidays, training, temporary duty assignments, and moves will all impact the time a provider has available to see patients.

Given inpatient and administrative responsibilities, clinic appointment hours might average 35 hours per week. Starting with

52 weeks, there are four weeks of leave plus three weeks for holidays, sick leave, and TADs/TDYs. Thus, a full time clinician

might be expected in the clinic for approximately 45 weeks out of the year. This equates to 1,575 hours per year per FTE PCM

that are available for appointments.

FTEs/Assigned PCM: The last factor is to account for the unique mission that military providers must also fulfill. Exercises,

deployments, mission-related training, and administrative duties reduce the amount of time that a military provider is

available to provide patient care. This factor is perhaps the most locally sensitive. The Tri-Service Readiness Costing Working

Group uses an estimate of 90% i.e., military providers spend an average of 10% of their time on readiness-related tasks.
55

Concepts

As discussed previously, wellness and

illness are two widely separated points on

the health continuum. The primary goal

of the MHS is to optimize the health of

all our beneficiaries. To optimize

health, “our focus will shift from

providing primarily interventional

services to better serving our beneficiaries by preventing injuries and illness,

improving the health of the entire

population while reducing demand for

the more costly and less effective

tertiary treatment services” (MHS

1999). Associated with varying levels of

health along the health continuum are

levels of prevention: primary, secondary

and tertiary.

Primary prevention strategies Primary prevention strategies

prevent the occurrence of disease and

injury. Primary prevention measures are

of two types: general health promotion

measures and specific health protection

measures. Both types of measures are

included in the DoD definition of health

promotion as “any combination of health

education and related organizational,

social, economic or health care interventions designed to facilitate behavioral and

environmental alterations that will

improve or protect health. It includes

those activities intended to support and

influence individuals in managing their

own health through lifestyle decisions

and self-care” (DoDD 1010.10). Examples of health promotion measures

include physical fitness, stress management and tobacco cessation programs.

Examples of health protection measures

include immunizations, environmental

sanitation and protection against

accidents and occupational hazards.

Secondary prevention strategies Secondary prevention strategies

provide for the early detection and

prompt treatment of disease and injury

(i.e., case finding). Examples of secondary prevention activities include clinical

preventive service delivery (e.g., HTN

screening, pap smears) and occupational

surveillance.

Tertiary prevention strategies ertiary prevention strategies involve

the treatment and management of

individuals with existing clinical disease

and include rehabilitation where residual

damage has already occurred. Examples

of tertiary prevention include insulin

therapy for patients with diabetes and

anti-inflammatory medications for

patients with asthma.

Although many of the comments in this

section will be addressed to healthcare

providers in MTFs and clinical units of

the operational forces, everybody can and

should provide or support health

promotion and health protection

initiatives. These initiatives are vitally

important, because they serve as primary

prevention strategies for many of the

conditions and diseases that ultimately

adversely affect the health of military

populations and strain resources.

Processes

A variety of processes are used to improve

the quality and appropriateness of health

service delivery and to therefore contribute to improved health, lessened disease,

improved patient and staff satisfaction,

increased capacity and (ultimately)

lessened demand for healthcare service—

in short, to an optimized MHS.

Evidence-Based Medicine (EBM) Evidence-Based Medicine (EBM) “is

the conscientious, explicit and judicious

use of current best evidence in making

decisions about the care of individual

patients” (Sackett 1998). It should be the

basis of not only preventive service and

condition/disease management programs

but also all that we do.

Evidence-Based Clinical Practice Evidence-Based Clinical Practice

Guidelines (CPG) Guidelines (CPG) are available for

Evidence-Based Primary, Secondary, and Tertiary Prevention

The Green H Award

Many ships and commands of the Navy Surface Forces have seen an increase in

the number of health assessments performed and a significant decrease in the

rates for tobacco usage, failure to meet weight standards, failure to pass the

physical readiness test and alcohol-related events. This is attributed to their

competition for the “Green H” award. Applications for this award are submitted

by Commanding Officers and include a description of the unit’s health promotion goals, activities and measures of effectiveness; the results of physical

readiness testing for the preceding two cycles; the number of health risk appraisal assessments completed; an assessment of crew education/counseling and

monitoring for nine health promotion areas and a description of a best practice

that could be instituted fleet-wide. Winners of the Force Commander Annual

Wellness Unit Award are authorized to paint a Green “H” on their bridge wing—

something for which they “will fight long and hard.” This is an example of a

policy that rewards health promotion activities and ultimately decreases risk

factors. For more information see COMNAVSURFPACINST 6100.1.
56

many recommended preventive services

and condition/disease management

programs. They provide practitioners

with a decision-making tool for determining appropriate health care for

specific clinical circumstances. They offer

an opportunity to improve health care

delivery processes by reducing unwanted

variation. As recommended by the

Institute of Medicine, practice guidelines

should be valid, reliable, and reproducible; clinically applicable and flexible;

multidisciplinary; reviewed on a scheduled basis; and well documented. The

DoD/VA Guidelines are available at http://

www.cs.amedd.army.mil/qmo/Home.htm.

The National Guideline Clearinghouse

(http://www.guideline.gov) has links to

many guidelines as well.

Clinical Preventive Services Clinical Preventive Services: The

Assistant Secretary of Defense (Health

Affairs) has written that;

“Services shall develop strategies and

systems to successfully implement PPIP

at all MTFs and DTFs worldwide,” and

“MHS implementation of PPIP supports

the transformation of healthcare delivery

focus from treatment of illness and

injuries to health promotion and

wellness, prevention of illness or injuries,

and improving the health of TRICARE

PRIME enrollees” (OASD[HA] 1998).

Put Prevention Into Practice (PPIP) Put Prevention Into Practice (PPIP

is a national campaign developed by the

office for Disease Prevention and Health

Promotion, Department of Health and

Human Services and currently administrated by the Agency for Healthcare

Research and Quality (http://

www.ahrq.gov/clinic/ppipix.htm). PPIP

is designed to improve the delivery of

clinical preventive services in primary

care settings, including immunizations,

screenings, and health counseling.

Health Promotion and Risk Reduc- Health Promotion and Risk Reduction: Health promotion is : “any combination of health education and related

organizational, social, economic or

health care interventions designed to

facilitate behavioral and environmental

alterations that will improve or protect

health. It includes those activities

intended to support and influence

individuals in managing their own

health through lifestyle decisions and

self-care. Operationally, health promotion

includes smoking prevention and

cessation, physical fitness, nutrition,

stress management, alcohol and drug

abuse prevention, and early identification

of hypertension” (DODD 1010.10). Risk

reduction refers to interventions designed

to facilitate behavioral and environmental alterations that will decrease risk

factors that adversely affect health and

safety.

Clinical Case Management Clinical Case Management is a

collaborative process which assesses,

plans, implements, coordinates, monitors, and evaluates options and services to

meet an individual’s or populations’

health needs through communication

and available resources to promote

quality cost-effective outcomes (adapted

from CMSA, 2000). Clinical case

management may be applied across the

entire health care continuum. TRICARE

Management Activity (TMA) has established a Broad-spectrum Case Management Program (BCMP) to address the

spectrum of patient needs. Needs range

from patients who are currently disease

free but are demonstrating unhealthy

behaviors, to patients who are acutely ill,

The Challenge

As new health technologies and prevention strategies are identified, the challenge

is to change individual practice so that the most effective interventions are utilized.

Stated differently:

How does one get a group of physicians or providers to provide the desired

preventive service to a target population so that the majority of the population

most likely to benefit from the services actually receives it at appropriate intervals?

There is a two-fold answer to this question:

1. Information is not enough as new technologies on drugs and other

advances are produced, efficacious treatments diffuse quite slowly through

communities, through the social and professional interactions of physicians in

their local meeting places. Consequently, considerable effort must be made to

target health care leaders with the introduction of such topics to generate enthusiastic support within the local professional community for such treatments. In

addition, rarely do new technologies replace or supplant old technologies.

Information in the form of linkages and new algorithms of clinical practice must

continue to test activities and practice patterns that are comfortable. Preventive

services in the medical communities provide for such opportunities.

2. Incentives affect the organization and delivery of preventive health care.

Remuneration may come in several forms to include monetary, professional

clinical and educational satisfaction, and use of time both at work and home.
57

to patients who are at high risk. More

information may be found at the TMA

Case Management Website at http://

www.tricare.osd.mil/opt_int/

Clinic_ProvInf.htm. Along this continuum are:

 Population-Based Case Management (PBCM) includes interventions

such as health promotion, risk factor

reduction counseling and clinical

preventive service delivery. Some of

these interventions may be performed by health promotion

personnel, food service or other

ancillary personnel or by worksite

and community-based health

program personnel. Other of the

interventions will be performed by

members of the clinic team; some by

the primary care provider and others

by other members of the team.

Population-based Case Management

targets a subset of the total population that demonstrates unhealthy

behaviors or is at high risk for

specific disease categories.

 Condition and Disease Management: The following descriptions

will be used in this document and

are the ones that will be used by

TRICARE Management Activity.

Condition and Disease Management

are prospective, condition or diseasespecific approaches to delivering

health care that span all encounter

sites (inpatient, outpatient, ER,

home care) and cross the continuum

of care. Condition Management

includes care of patients with

transient physiological states such as

pregnancy, behavioral or lifestyle

conditions (risk factors) such as

tobacco use, and chronic conditions

such as obesity. Disease Management includes managing the care of

patients with specific illnesses or

disorders.

Both Condition Management and

Disease Management augment

credentialed providers with noncredentialed providers who specialize

in the target conditions and provide

patients with additional education

and manage the effects of their

conditions. Both target high-cost,

high-volume, chronic, and complex

conditions. Both include clinical

algorithms depicting decisions and

interventions that are based upon

evidence from scientifically rigorous

studies. Ideally both Condition

Management and Disease Management should extend beyond merely

implementing clinical practice

guidelines (CPG) and clinical/

critical pathways. They should be

customer-focused and proactive

while promoting efficient, effective

services. They are designed to reduce

unwarranted variation in practice,

improve clinical outcomes, satisfy

accreditation requirements and

should ultimately improve enrollee

and staff satisfaction. They also offer

a great opportunity to ensure that

services throughout the MTF

(including health promotion and

occupational health) are integrated

with worksite and community

programs.

 Individually-based Case Management (ICBM) includes interventions

ranging from Care Coordination to

Individual Case Management (ICM)

by a clinical case manager. Care

Coordination is provided by any

member of the health care team for

patients who needs assistance in

navigating the health care system,

are at-risk or high-risk or have

complex problems. Individual Case

Management is provided by case

managers for patients who are at the

highest risk, have the most complex

problems, or have an extraordinary

condition.

 Persons with Extraordinary

Conditions (ICMP—PEC) : A

specific program in which

designated case managers target

a very specific population. DoD

mandates consideration for

Case Management patients with

the following diagnosis and

procedures: head trauma, spinal

cord injury, HIV infection/AIDS,

neoplasm, NICU admission,

bone marrow procedures and

burns. The coordination of

services for patients with

specified extraordinary conditions has been contracted to the

Managed Care Support Contractors.

Roles

Health Promotion Program Officer/ Health Promotion Program Officer/

Team (or equivalent): eam (or equivalent): A Health

Promotion Program Officer/Team

coordinates a systematic approach to

health promotion and establishes or

ensures establishment of health promotion programs IAW DoD Directive 1010.10

and Service-specific instructions (i.e.,

OPNAVINST 6100.2, BUMED Instruction

6110.13; Air Force Health Care Integrator

functions, see PCO at https://

phsd.afms.mil/PHSO/). Individual,

worksite, and community-based health

promotion and health education

programs must be planned, resourced,

and implemented to improve the health
58

of populations.

Condition/Disease Management Condition/Disease Management

Teams: Multidisciplinary teams (typically led by a credentialled provider)

formulate and administer Condition and

Disease Management Programs. The

steps to be taken by the team are to:

identify and assess the population, choose

several possible targets, prioritize targets,

acquire data, choose an appropriate CPG,

implement the CPG and evaluate the

effectiveness of the CPG. Detailed

information about this process is

available in numerous publications and

at several websites referenced in the Tools

section under Evidence-Based Medicine

and Clinical Practice Guidelines.

Utilize staff members Utilize staff members other than

privileged providers to provide education,

care and follow-up as appropriate using

approved protocols. Ensure that duties

and responsibilities are clarified, that

protocols, scripted dialogues, and roles

are written and approved and that all

personnel are being used to their fullest

potential. Several articles have been

published on examples of nurse managed

clinics (Health Care Reengineering

Review 2000 and Savage 2000). Consider

alternatives to traditional visits such as

group appointments (Masley, Sokoloff

and Hawes 2000), telephone consultations, e-mail communication, and webbased offerings to increase efficiency and

access as well as increase patient satisfaction. Consider subscribing to (and

sharing your innovations through) The

Reengineering Review (http://

www.tricare.osd.mil/hcr/) to keep

informed about innovations in the MHS.

Consider how worksite care providers

(many of whom have their own condition/disease management programs) and

community-based resources can work

with MTF-based teams (including health

promotion personnel) to offer wellrounded, comprehensive and userfriendly programs. Ensure your program

addresses primary prevention (what

activities are in place to prevent the

condition/disease from occurring) and

secondary prevention (what activities are

in place to provide early detection and

prompt treatment of the condition/

disease). Plan into your program how

you will measure and analyze outcomes.

Clinical Case Manager: Clinical Case Manager: MTFs should

have a designated Clinical Case Manager

to whom patients (either inpatients or

outpatients) who meet specific criteria are

referred for management. Personnel at

the clinic or worksite level should also

provide a version of clinical case management (which may be less formalized)

for patients who do not meet criteria for

referral but for whom special attention is

warranted. Often the nurse will fulfill this

role. However, a social worker or, in the

case of small units, the sole medical

representative might perform the role.

Examples of patients warranting special

attention include those with clinic

utilization rates higher than expected;

multiple stressors (e.g. new to the area,

spouse deployed, no support system,

financial difficulties and new onset

disease) and multiple diseases (e.g.

diabetes, hypertension and asthma).
59

Tools

Health Promotion: Health Promotion: Information is available on Service-specific programs at:

Army: http://chppm-www.apgea.army.mil/dhpw

Navy: http://www-nehc.med.navy.mil/hp/index.htm

Air Force: https://www.afms.mil/op_prev/hlthprom.cfm

Evidence-Based Medicine (EBM): Evidence-Based Medicine (EBM): In addition to a variety of books (Eddy 1996; Muir 

Gray 1999; Sackett 1998 and Handley 2000)there are also on-line sources of information

such as the Center for Evidence-Based Medicine at http://cebm.jr2.ox.ac.uk. The three

Services have more information. Navy personnel should contact https://

bumed.med.navy.mil/med03/ebm. Air Force information is found at https://

phsd.afms.mil/PHSO/. Army contact: http://www.cs.amedd.army.mil/qmo/Home.htm.

Put Prevention Into Practice (PPIP ): Extensive information, references and tips for ):

implementation (including an on line version of the Clinician’s Handbook of Preventive

Services) are available at http://www.ahrq.gov/clinic/ppipix.htm. A full description of the

studies upon which the PPIP guidelines were developed is available in print (U.S. Preventive Services Task Force 1996) or at http://www.ahcpr.gov/clinic/cpsix.htm. Use of agespecific approved DD Forms (e.g. DD 2766) will facilitate continuity of care throughout

the MHS. The Navy’s website and information about their training course is available at

http://www-nehc.med.navy.mil/hp/ppip/index.htm. Information about PPIP in the Air

Force can be found at programs/tools at https://phsd.afms.mil/PHSO/. Information

about PPIP in the Army can be found at http://chppm-www.apgea.army.mil/dhpw/.

Clinical Practice Guidelines (CPG) Clinical Practice Guidelines (CPG describe what care a patient with a given condition/disease should be provided. A variety of CPGs exist ranging from those that are

explicitly evidence-based to those that are based only on expert opinion or consensus. Due

to the investment required to develop, adapt and maintain guidelines, and to ensure

continuity of care across the system, DoD/VA CPGs are recommended when appropriate for

the local population and specific disease management programs. DoD/VA Guidelines and

additional information are available at http://www.cs.amedd.army.mil/qmo/Home.htm.

Preferential consideration is given those conditions that have been identified as being high

cost, high volume, high risk and/or problem prone in both systems. To date, DoD/VA

Guidelines are available for Tobacco Cessation, Low Back Pain, Cardiovascular Disease

(Hypertension and Hyperlipidemia), Asthma, Chronic Obstructive Pulmonary Disease,

Diabetes Mellitus, Depression and Uncomplicated Dysuria in Women. They include tools

for implementation. The National Guideline Clearinghouse (http://www.guidelines.gov)

provides a catalogue of a variety of guidelines, however be advised that no critical

appraisal of the guidelines is provided. Army information is available at http://

www.cs.amedd.army.mil/qmo/Home.htm. Navy personnel may also contact https://

bumed.med.navy.mil/med03/ebm for more information. Air Force support for CPGs is at

programs/tools at https://phsd.afms.mil/PHSO/.
60

Clinical Pathways Clinical Pathways describe the local “who, where, when and how” for the implementation of the “what” in the CPG. Critical Pathways Critical Pathways are similar but geared

toward inpatient care and also include expected milestones.

Case Management: Case Management: More information is available at http://www.cmsa.org (The Case

Manager’s Society of America) or in the Case Manager’s Toolkit, which is available

from your Service Representative. Army should contact Pam Harris at (210) 221-6195

or DSN 471. Navy should contact https://bumed.med.navy.mil/med03/clinical. Air

Force support is located at programs/tools, PCO, and education at https://

phsd.afms.mil/PHSO/.

Web Sources of Health/Illness Information: eb Sources of Health/Illness Information A variety of web resources are

available for patient and healthcare personnel information about a variety of conditions and diseases. Browse through http://www.healthlinkusa.com, http://

www.firstgov.gov/ or http://www.healthfinder.gov to see a sample of what is available

online.

Systematic evidence reviews have been completed that identify effective programs

both for tobacco use prevention and control and for tobacco cessation (U.S. Preventive Services Task Force, 1996). There is sufficient evidence to

support a multifaceted approach that includes worksite and

community-based programs and clinical interventions. The VHA/

DoD Clinical Practice Guideline “Tobacco Use Cessation in the

Primary Care Setting” provides guidance for primary care interventions targeting current tobacco users, for assessing the risk of a

non-tobacco user to start using tobacco products, and for assessing the risk of a

former tobacco user to resume using tobacco products. This guideline, an implementation toolkit, and patient and provider education materials are available at

http://www.cs.amedd.army.mil/qmo/smoke/smoke.htm.

The “Clinician’s Handbook of Preventive Services” provides a detailed outline of the

basics of smoking cessation counseling. It also includes information about nicotine

replacement and other pharmacological agents for smoking cessation (U.S. Public

Health Service, 1997).

National Asthma Education and Prevention Program

The National Asthma Education and Prevention Program (NAEPP) is administered and coordinated by the National Heart, Lung, and Blood Institute (NHLBI).

The NAEPP works with intermediaries including major medical associations,

voluntary health organizations, and community programs to educate patient,

health professionals, and the public. The ultimate goal of the NAEPP is to

enhance the quality of life for patients with asthma and decrease asthma-related

morbidity and mortality. The NAEPP Website is http://www.nhlbi.nih.gov/about/

naepp/index.htm.
61

References

Department of Defense (DoD). Directive

1010.10.

Eddy, DM. 1996. Clinical Decisionmaking From Theory to Practice.

Sudbury, MA: Jones and Bartlett Publishers.

Handley, MR, et al. 2000. Evidence-based

Medicine & Clinical Practice Guidelines. Seattle, WA: Group Health Cooperative.

Health Care Reengineering Review. 2000.

Nurse-Managed Clinic at Naval

Ambulatory Care Center Groton

Primary Care Center. Available at http://

www.tricare.osd.mil/hcr/.

Masley, S, J Sokoloff and C Hawes. 2000.

Planning group visits for high-risk

patients. Family Practice Management

7(6):33. Available at http://

www.aafp.org/fpm/.

Military Health System (MHS). 1999.

Optimization Plan, Interim Report.

Available at http://www.tricare.osd.mil/

mhsoptplan.

Muir Gray, JA. 1999. Evidence-based

Healthcare. London, England: Churchill

Livingstone.

Office of Assistant Secretary of Defense

(Health Affairs) (OASD(HA)). 1998.

Policy for Put Prevention Into Practice.

Policy 9800027.

Sackett, DL, et al. 1998. Evidence-based

Medicine: How to Practice and Teach

EBM. London, England: Churchill

Livingstone.

Savage, A. 2000. Nurse-managed clinic

improves care for acne patients. American Academy of Ambulatory Care

Nursing 22(6):1, 8-10.

Baltimore, MD: Williams & Wilkins.

U.S. Public Health Service. 1997.

Clinician’s Handbook of Preventive

Services. McLean, VA: International

Medical Publishing.

U.S. Preventive Services Task Force. 1996.

Guide to Clinical Preventive Services.
62
63

Concepts

To review, communities are collections of

people that can be described by geographic (people in specific geographic

boundaries) and/or functional (common

interests, association, occupation

services) characteristics. A healthy

community creates a psychological sense

of connection, develops resources and

opportunities for meeting individual and

collective needs, offers opportunities for

personal and group development, and

adequately responds to external threats. A

healthy community has the capability to

continually improve the physical and

social environment of its members, and is

committed to modifying behavioral,

social and physical environmental factors

that impinge on one’s health.

Community outreach is essential if we are

to achieve the Service Delivery System

End State Vision of a population health

focus as set forth in the MHS Optimization Plan. The vision states that “The

health of the population will be paramount—we will move from focusing

primarily on interventional services to

better serving our beneficiaries by

preventing illnesses and injuries through

their full life cycle. Prevention and

screening programs will be fully deployed

and measurable. Beneficiaries will be full

partners in all their health decisions”

(MHS 1999).

Community outreach addresses educational, policy and environmental

strategies within a variety of settings

(schools, health care facilities, worksites,

places of worship, etc.). These interventions target the multiple determinants of

individual and community health which

include such things as local environmental quality and hazards; quality of

housing, education and transportation,

spiritual, cultural, and recreational

opportunities; social support services and

structures; employment opportunities;

and effective mechanisms for collectively

addressing community concerns.

Participants involved in developing a

healthy community should come from a

broad variety of installation and civilian

community leaders and stakeholders. A

team approach integrating the efforts of

all is critical.

Processes

Community outreach has processes that

are analogous to improving the health of

a defined beneficiary population.

However, the concepts extend beyond

medical interventions focused on

individuals or a population with a given

disease. They include local environmental quality and hazards; quality of

housing, education, and transportation;

spiritual, cultural and recreational

opportunities; social support services;

diversity and stability of employment

opportunities; effective local government;

etc. Impacting these elements requires

long-term and dedicated planning and

cooperation between the local military

commanders and civilian community

leaders. Such efforts should be modeled

after successful cooperative programs

already developed by local, state and

federal governmental health agencies;

schools of public health and other

academic institutions; local business

coalitions; community action groups; etc.

Similarly, already developed community

health outcome metrics (e.g., Healthy

People 2010 available at http://

www.health.gov/healthypeople/document) should be evaluated for adoption.

Community health status and needs must

be assessed, prevention and condition

management interventions applied,

outcomes monitored for effectiveness, and

methods established for addressing

ongoing basic community issues/

problems.

Roles

To accomplish the above in the Department of Defense communities involves

work at several levels.

At the DoD level At the DoD level, The Prevention, Safety

and Health Promotion Council is a TriService council whose charter is to

“advance health and safety promotion

and injury/illness prevention policy

initiatives that are consistent with

Department of Defense readiness requirements and the MHS Strategic goals of (a)

a constantly fit and ready force and (b)

healthy communities at home and

abroad, in peacetime and in conflict.” It

addresses community needs and resources, as well as the deployment of the

Health Enrollment Assessment Review,

Put Prevention into Practice, and other

such programs. It also addresses policy,

ensuring effective system-wide communication of all approved health promotion

and injury/illness prevention policies and

implementation instructions. The

subgroups of this council include:

 Put Prevention into Practice

Program Implementation Advisory

Committee

 Joint Preventive Medicine Policy

Group

 Alcohol Abuse/Tobacco Use

Reduction Committee

 Self-reporting Tools Work Group

 Sexually Transmitted Disease

Prevention Committee

 Injury/Occupational Illness

Prevention Committee

Community Outreach
64

To manage the overall health of a

community-installation, at the local

level, a Community/Installation Population Health Council needs to be developed. Representation on the council

should include: line/command, health

care providers and agency representatives

responsible for activities related to such

areas as safety, morale, welfare, spiritual

fitness, recreation, transportation,

housing, and fire and police services. The

following subtasks should be included in

developing a healthy geographic and

functional community:

 Identify key stakeholders and

community support organizations.

Ensure those within the community

as well as those who support the

community externally are included.

 Obtain stakeholder and

organizational commitment to

developing a healthy community.

 Assess the community—address

strengths, weaknesses, opportunities,

and threats. Assess measures of

community resilience, cohesion and

capacity.

 Review the population assessment (see sections Identify the

Population and Evidence-based

Interventions).

 Identify and prioritize community needs. Examples may include

decreasing risk behaviors (especially

those related to tobacco and alcohol

use); reducing specific diseases,

injuries, and impairments; targeting

specific health needs of the population; providing activity and nutrition

programs; enhancing mental and

spiritual health or addressing

environmental and ecosystem

challenges. The Guide to Community Preventive Services and Healthy

People 2010 (both listed below as

resources) may provide additional

population needs for the council’s

consideration.

 Obtain consensus by members

and stakeholders on these needs.

Community Involvement Example of the Integrated

Delivery System for Suicide Prevention

BACKGROUND: In early 1996 the Air Force Vice Chief of Staff commissioned an

Integrated Product Team (IPT) to study and develop recommendations on suicide

prevention. A deliverable of the IPT on suicide prevention was the development of

the Integrated Delivery System (IDS). The IDS centralizes helping functions from

both the Line and Medical functions into one delivery system for providing

prevention services to the community.

COMMUNITY IDS MODEL: The goal of the IDS is to be a seamless, central point of

help for the community and to be effective in the delivery of collaborative preventive services. There are four primary functions of the IDS:

1. Centralized information and referral source

2. Provide assessment of community risk factors

3. Delivery of prevention services to the community at large

4. Collaborative marketing

SUICIDE PREVENTION RESULTS: The Air Force Active Duty community has

continued to see a decline in the number of suicides over the past five years and

most dramatically over the past year. As of 16 December 1999, there have been 19

suicides in CY 99 for a total rate of 5.6/100,000 in comparison to 33 suicides at this

time in CY 98 for a total rate of 9.6/100,000. The overall rate has declined over

40% in this time and 78% since CY 94.

PLAN FOR THE FUTURE: Improve on “Community Capacity” of Air Force

communities. Community Capacity is defined as those informal networks,

community agencies, and unit leaders that impact on community results. The

concept of “Community Capacity” is the extent to which community members:

§ Demonstrate a sense of shared responsibility for general welfare of

community and its members

§ Show collective competence in taking advantage of opportunities

addressing community needs and confronting situations that threaten integrity of

the community and safety and well being of its members

STRATEGIES FOR IMPROVING COMMUNITY INVOLVEMENT:

§ Adopt “Community Capacity” as key factor in IDS initiatives (IDS is the

“how” and Community Capacity is the “what”)

§ Develop and track key indicators of “Community Capacity”

§ Educate installation organizations and Commanders

§ Implement action plans through total community approach
65

 Develop community-wide action

plans to address these identified

needs with specific measures for

evaluation of the intervention.

Programs should target the proactive

delivery of primary and secondary

prevention services as well as

interventions targeting condition/

disease management. Ideal metrics

should be outcome-oriented, or those

evaluating the effect of the interventions. However, process metrics, such

as evaluating the quality and

quantity of the processes implemented to achieve the outcome

might be the only valid metrics

available initially. For example, to

address a problem of teen violence in

the neighborhood, a process metric

might be the number of teens

enrolled in after-school programs

whereas the target metric – the rate

of teen violence – is the outcome

metric. In addition, metrics should

be objective as well subjectively

targeted, ensuring perceptions,

feelings, etc. are simultaneously

measured with objective measures

such as statistical changes.

 Implement the action plans

through a total community approach, continually collecting

appropriate data for metric evaluation. Provide educational and

community-based programs that are

age and culturally specific and

which involve the entire community.

Use available community resources:

think “out of the box” (e.g., work

with local churches and schools to

help them develop exercise classes

for seniors).

 Evaluate the interventions,

ensuring a variety of stakeholders

and members analyze the data and

subsequently determine modifications to the community action plan.

 Establish a mechanism to

continually evaluate the community

and to analyze trends to identify

actual as well as potential/evolving

health complications developing in

the community/population.

Tools/Resources

Healthy People 2010 is a comprehensive, nationwide health promotion and

disease prevention agenda. It is designed

to serve as a roadmap for improving the

health of all people in the United States

during the first decade of the 21st century.

It is grounded in science, built through

public consensus, and designed to

measure progress. It is available at http:/

/www.health.gov/healthypeople/document.

Guide to Community Preventive Guide to Community Preventive

Services Services addresses a variety of health

topics important to communities, public

health agencies and health care systems.

It summarizes what is known about the

effectiveness and cost-effectiveness of

population-based interventions designed

to promote health, prevent disease, injury,

disability and premature death as well as

exposure to environmental hazards.

More information about the “Community

Guide” is available at http://

www.thecommunityguide.org including

chapters on tobacco product use prevention and vaccine preventable diseases as

well as the tentative publication dates for

future chapters (motor vehicle occupant

injury May 2001 and physical activity and

diabetes June 2001).

Examples of Air Force programs Air Force programs that

link medical programs and community

outreach include the Health and Wellness

Centers (information available at Health

Promotions, http://www.afms.mil/

op_prev/hlthprom.cfm and Family

Preventing the innumerable adverse health effects attributed to tobacco use requires

a comprehensive approach targeting three areas: 1) reduce exposure to environmental tobacco smoke, 2) reduce tobacco use initiation, and 3)

increase tobacco use cessation. There is substantial evidence

showing that a comprehensive approach would include worksite

and community-based programs as well as clinical interventions.

The Task Force on Community Preventive Services has identified

recommendations, supported by evidence, that target the three

areas listed above (Task Force on Community Preventive Services 2001). Some of

the key recommendations that require community or worksite interventions are: 1)

smoking bans and restrictions for designated areas ranging from individual

worksites to entire communities, 2) increasing the price of tobacco products and, 3)

mass media campaigns to inform and motivate children and adolescents to remain

tobacco-free.

Military Health System programs can partner with military installation and civilian

community programs to ensure a comprehensive approach is used to reduce tobacco
66

Advocacy, http://www.afms.mil/

com_prev).

References

Military Health System (MHS). 1999.

Optimization Plan, Interim Report.

Available at http://www.tricare.osd.mil/

mhsoptplan.

Task Force on Community Preventive

Services. 2001. Recommendations

regarding interventions to reduce tobacco

use and exposure to environmental

tobacco smoke. American Journal of

Preventive Medicine 20(2S):10-15. The

Task Force on Community Preventive

Services reports on tobacco can be

accessed by selecting topics at http://

www.thecommunityguide.org/.
67

Concepts

Standardized performance measures will

be used to analyze the performance of the

health care delivery system, the health of

the population, and the quality of the

clinical services provided to our beneficiaries. Performance-based measurement is

essential to evaluate the effectiveness of

the health system in meeting goals and

objectives. Performance measures will

include clinical measures for direct

comparison to other health care systems.

Health status measures of the population

reflect the orientation of the organization

and are crucial for successful clinical

management decisions. Also, timely,

data-oriented feedback on critically

selected performance measures will be

given to providers and facilities to assist

them in improving clinical processes. At

the enterprise level, aggregate measures

of performance, or metrics, will be used

to evaluate the progress of population

health improvement initiatives.

To put performance assessment into

action, the MHS should utilize an

enterprise-wide core set of standardized

performance measurements. Examples

are TRICARE Operational Performance

Statement (TOPS) and Population Health

Operational Tracking and Optimization

(PHOTO) (see Tools below). The use of

National Committee on Quality Assurance (NCQA) Health Plan Employer Data

and Information Set (HEDIS) performance indicators allow for standardized

comparison across the MHS system and

with other health care systems. Special

interest and/or Service specific metrics

may be added to this common core.

Military Treatment Facilities and

Regional Lead Agent population health

offices will utilize current resources,

where available, to capture information

and decrease redundant efforts among

MTFs and Managed Care Support

Contractors. Services will attempt to

integrate preventive services and condition management measures with

indicators already required and collected

for other quality assurance programs

such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

ORYX, HEDIS, the DoD National

Quality Management Program and other

mandated programs. Eliminating

duplicative efforts is essential, and reports

should address specific goals and

objectives for the improvement of health

care services.

Performance and Health Status Performance and Health Status

Measurement: Measurement: Measures must be

developed that describe the population’s

health status and support periodic

measurement to track progress toward

improving health and delivery system

performance. Categories to measure

include clinical impact and process

measures, patient-centered outcomes,

and system-performance outcomes.

Measures must also be helpful in focusing

on a prioritized set of predetermined

questions that will support or justify

resource allocation under a set of

predetermined assumptions. Patient-level

measures that can be aggregated to the

provider, the MTF, and the Region are

ideal.

Process measures Process measures are used to assess the

processes of health services delivery. They

must be developed to answer meaningful

questions related to clinical and business

processes. Examples of the questions that

can be answered by carefully developed

measures are: How effectively are

diabetics being identified and tested for

hemoglobin A1C levels and urine protein,

or receiving annual eye and foot exams?

How is the MTF doing at completing

recommended cervical cancer screening

for enrolled women and how does the

MTF performance compare with benchmark health plans?

Clinical impact measures impact measures reflect the

status of disease or injuries, risk factors,

contributing factors, surrogate indicators

in a population, or absolute results of

clinical values for a study or procedure.

For example: the average hemoglobin

A1C for the diabetic population of X

provider is 8.2, with a normal range of 6-

8; incidence of head injuries in children

6-12 years of age decreased from p/1000

to y/1000; Zung depression scores average

Y on patients being treated for depression

with antidepressants.

Patient-centered outcomes outcomes focus on an

enrollee’s viewpoint, the self-perceived

value of a service or the quality-of-life

impact of interaction with the system.

Examples include: 98% of female

enrollees considered their gynecological

care to be good or excellent; 22% of men

age 55 to 64 were able to walk without

pain for one mile or more two months

after hip surgery.

System-performance measures System-performance measures are

more comprehensive than the process

and impact measures. Many of these

indicators should be taken from inspection worksheets from the various agencies

that certify hospitals, clinics and health

plans in order to reduce duplication of

effort at the MTF level. All target values

are subject to periodic validation and

benchmarking to civilian and military

unique specifications. The following are

examples to clarify this discussion:

Analyze Performance and Health Status
68

 Access: Target would be 90 % of

enrollees who tried to make a

routine appointment were able to do

so within one week. The actual time

period may be different based on

severity of the problem and whether

the appointment is with a PCM or a

subspecialist.

 Continuity: Target would be 70 % of

patients enrolled to clinic XX were

able to see the same provider at least

two or more times in succession over

a 12-month period if they require

that frequency of visit.

 Quality: 99% of eligible providers in

clinic XX have their specialty board

certification.

 Financial: 80% of clinics within XX

MTF produce episodes-of-care costs

equivalent to outsourcing costs.

 Training: 98% of individuals

providing direct patient care within

the facility have their BLS certification.

Processes

It is important to measure the use of

critically analyzed, evidence-based

medicine practices in clinical practice.

Performance measurements will drive the

delivery of evidenced-based clinical

services. Evidence-based practice is

aimed at maximizing health outcomes

for the population within the constraints

of limited resources. Services will guide

facilities in identifying and closing gaps

between current clinical practices and

optimal practices. Clinical decisions will

be based on best available evidence that is

critically appraised and summarized, and

conclusions will be used to assist providers and patients in making health care

decisions. Performance will be continuously monitored at the provider level.

Measures evaluate both effectiveness of

interventions (clinical effectiveness) and

effectiveness of the system implementation of evidenced-based practice (implementation).

Performance measures at the local level

will be designed to assess the health of the

population, the quality and cost effectiveness of the delivery system, and the

impact of clinic practice on the individuals treated. Measures selected will reflect

performance targets that are meaningful

to the customer and provider, and which

can be used directly to improve performance. Clinical measures may be health

outcomes, impact measures, or process

measures. Facilities will be able to:

 Identify and prioritize clinical

areas requiring reengineering.

 Conduct critical analysis of the

health needs of their enrolled

population.

 Define performance measures

that ensure process improvement.

 Define these measures so the

patient understands them.

 Utilize the measures effectively

to improve clinical outcomes.

Utilization Management: Utilization Management: The Military

Health System (MHS) is moving from

what has been seen as “prescriptive”

utilization management (UM) to a

population-based health management

model that incorporates key elements of

UM within the population health

improvement process. In the past, UM

has often been mistakenly equated with

one UM tool – utilization review – which

may result in a negative reputation for

appearing to focus only on reducing bed

days, denying care, and constraining

provider practice.

But utilization management has always

been more than just utilization review.

The best models of utilization management have recognized that UM must be

linked to quality management (QM) to

support the readiness mission and deliver

“best value” health care that balances

customer service, high technical quality,

and lower costs. The model combining

QM and UM includes many elements,

such as epidemiological assessment,

capacity management, demand management, health promotion and prevention,

case management, disease management,

education, practice guidelines, discharge

management, and performance and

outcome measures. Finally, the best

models have recognized that a combination QM and UM program is not just a set

of tools but an over-arching philosophy

that can achieve a cultural shift in the

entire organization, a shift to a performance-based, accountable health system

whose goal is to improve the health of its

population.

Roles

Service Medical Departments Service Medical Departments and

TRICARE Management Activity TRICARE Management Activity will be

held accountable to support this population health initiative. They will ensure

implementation of processes within their

facilities that reflect evidence-based

clinical practice. To accomplish this,

MHS and Region level offices will analyze

aggregate measures of performance

within and among Regions. Performance measures for MTFs should be

compared with aggregate rates to identify

MTFs that have benchmark results as well

as those that need to improve. Similar

Region-to-Region comparisons should be

made. Finally, MHS-wide results should

be compared with results from other large

health systems such as the Veterans

Administration or large managed health

plans. Using standardized measures such
69

as those found in HEDIS facilitate such

comparisons (Rohrer 1999).

Facility commanders Facility commanders are responsible

to develop an internal process to

identify and prioritize clinical and

business areas for improvement

and/or reengineering. Factors to

consider include evidence

supporting practice, patient

satisfaction, cost, volume, impact

on capacity, risk of harm,

potential for resource shifting, etc.

This medical chain of command

will be held accountable for this

process. A person trained in

epidemiology should facilitate

and guide this process. If not

available, commanders should

provide appropriate training to

responsible staff.

Commands Commands will participate in

provider information or profiling

reporting processes. The provider

support report will provide

performance measurement by

provider and clinic/department

for use by the facility commander.

The information gathered will be

used at the local level to measure

effectiveness of clinical interventions in meeting targeted

objectives and to identify areas for

improvement. The information

will be used as feedback in a nonpunitive, professional manner.

Information reported from the

MTF to the Service and enterprise

level will be aggregated, allowing

comparisons between facilities

only.

The MHS Optimization and Popula- MHS Optimization and Population Health Support Center (OPHSC) tion Health Support Center (OPHSC)

will facilitate data analysis and feedback

to improve MTF performance. The MTF

executive board should then review the

data to provide appropriate feedback to

the clinics needed to improve provider

performance.

Population Health Operational Tracking

and Optimization (PHOTO) Metrics

Customer Responsiveness

♦ Overall Satisfaction with Care Received at MTF (All Users)

♦ MTF Outpatient Visits Meeting the Wait Time AT Appointment Standard

♦ MTF Outpatient Visits Meeting the Wait Time FOR Appointment Standard

(Prime Enrollees for urgent and routine care in Primary Care Clinics Only)

Force Health Protection

♦ Active Duty Qualified for Deployment for Dental Health (Dental Classes 1 & 2)

♦ Active Duty Immunizations for Deployment

Population Health Improvement

♦ Breast Cancer Screening (HEDIS)

♦ Cervical Cancer Screening (HEDIS)

♦ Prenatal Care in the First Trimester (HEDIS)

♦ Childhood Immunization Status (HEDIS)

Best Clinical Practices

♦ Eye Exams for People with Diabetes (HEDIS)

♦ Follow-Up After Hospitalization for Mental Illness (HEDIS)

♦ Check-Ups After Delivery (HEDIS)

♦ Beta Blocker Treatment After a Heart Attack (HEDIS)

♦ Asthma Management

♦ Preventable Admission Rates for 9 Diagnoses Identified in the ASD(HA)

Performance Contract

Best Business Practices

♦ Per Member (User) Per Month (PMPM) Financial Metric

♦ Outpatient Visits PMPM/PMPY

♦ Specialty Referrals PMPM/PMPY

♦ Pharmacy Costs PMPM/PMPY

♦ World Wide Workload (WWR) to SADR Visit Count

♦ Discharges/1000 Enrollees

♦ Average Length of Stay

♦ Emergency Room Visits PMPM/PMPY

♦ Percent of Users Enrolled in Catchment Area

♦ Percent External Customer Workload
70

The, OPHSC, Service Headquarters, OPHSC, Service Headquarters,

Service intermediate commands, Service intermediate commands,

Regional Lead Agent offices and

Managed Care Support Contractors Managed Care Support Contractors

should attempt to integrate metrics to

decrease the measurement burden facing

MTFs. This includes integrating preventive services and condition management

metrics with metrics already required and

collected for quality assurance programs

such as JCAHO, ORYX, HEDIS, and the

DoD National Quality Management

Program and other mandated programs.

Military T Military Treatment Facilities reatment Facilities should

utilize, at a minimum, the targeted

metrics selected and distinct thresholds as

the basis for their quality improvement

activities. As conditions merit, an

expanded use of metrics may be encouraged and narrower thresholds utilized to

optimize performance. In all instances,

these improved tools should be communicated to Service intermediate commands, Regional Lead Agent offices, and

the Tri-Service Agency Executive Board in

standardized methods (to be developed)

for consideration in applying them to the

MHS as a whole. Ideally metrics will be

patient-level measures that can be

aggregated to the provider, MTF, Service

intermediate command, Managed Care

Support Contractor and Regional levels.

Service intermediate commands and

Regional Lead Agent offices will use MTF

profiling, while provider performance

reports will be utilized by MTFs.

Tools

The Population Health Operational Population Health Operational

Tracking and Optimization

(PHOTO) (PHOTO) System is a highly visible first

step toward an MHS-wide set of outcome

measures that addresses both business

and clinical practices, and focuses on

improving clinical care processes. It is

also the first visible step toward demonstrating the projected utility and value of

the MHS Data Repository (MDR). The

metrics that result from PHOTO are a

subset of the Tri-Service Common Core

Metrics. Planned PHOTO metrics are

listed in the accompanying text box.

PHOTO metrics can be accessed at http://

photo.tma.osd.mil/.

Clinical Practice Guidelines Clinical Practice Guidelines: The use

of evidenced-based clinical practice

guidelines for highest prioritized areas of

care is strongly encouraged (See key

process Evidence-based Primary, Secondary and Tertiary Prevention). For each

guideline that is implemented, at least

one performance outcome related to the

practice guideline will be measured.

Provider Information or Profiling Provider Information or Profiling

Reports Reports: Reports Profiling is the collection,

collation and analysis of clinical

utilization data to develop provider

specific information for resource consumption and outcomes for episodes of

care. These profiles should be used to

produce provider feedback reports to help

the providers modify and improve

practices, produce performance-based

incentives and perform resource or

economic modeling.

TRICARE Operational Performance TRICARE Operational Performance

Statement (TOPS) Statement (TOPS) captures and tracks a 

number of the measures reported

annually to the Defense Management

Council as part of the Defense Health

Program Performance Contract. Much of

the data is reported down to the MTF

level; at this time only the data quality

measure is reported to the clinic level (see

http://www.tricare.osd.mil/reptcard/tops/

topsrept.html).

Air Force Metrics: Air Force Metrics: The AF Surgeon

General has established a performance

measurement program (http://

p2r2va.tma.osd.mil) as an essential step

in promoting continuous process

improvement throughout the Air Force

Medical Service. The idea is to measure

Healthy People 2010 has 21 objectives related to tobacco use and exposure to

environmental tobacco smoke (Hopkins, 2001). While the objectives are mostly

long-term outcomes, they outline where organizations, such as

MTFs, can target processes to interrupt tobacco-related morbidity

and mortality. Clinics and MTFs can measure performance in

areas such as counseling smokers to quit, achieving smoking

cessation in pregnant women, and assessing the risk of tobacco use

initiation among non-users. Clinics may set near-term objectives

for performance in these and other areas outlined in the tobacco-related objectives.

All MTFs should review and evaluate health assessment information to identify

tobacco users in their populations and at health behavior surveys to analyze trends

in tobacco use in these populations. Reports should be provided to the clinic and

provider level to prompt action.

Consistent with Healthy People 2010 objectives, military communities can achieve

lower rates of tobacco use among all age groups. The proof of effectiveness of MTF

efforts will be a reduction in smoking-related morbidity and mortality and the

ultimate outcome will be improved health status.
71

success in the operation of the 79 Air

Force MTFs that can be used to establish

baselines - or “benchmarks” - for

continuous process improvement

throughout the organization.

The Air Force Air Force Population Health

Support Division generates quarterly quarterly

MTF data products MTF data products targeting AFMS

primary care optimization metrics for

preventive services. The data sets are

generated from systems available at the

MTF as well as databases which cannot be

accessed at the MTF such as enrollees

accessing care at other AF MTFs, sister

service MTFs, and network care. More

information is available at https://

phsd.afms.mil/PHSO/.

Navy Population Health Navigator Navy Population Health Navigator:

A CD-ROM database created by Navy

Medical Information Management Center

(NMIMC: http://

navmedinfo.med.navy.mil/) to provide

Navy MTFs with population-based

analysis capabilities. The tool enables

MTFs or clinics to describe the demographics, needs, and health status of the

enrolled and not-enrolled population,

and to manage medical and disease

conditions. For more information

contact CDR Turner at

mailto:mdturner@us.med.navy.mil.

Army Medical Information Manage- Army Medical Information Management products ment products are available at: ment products

Patient Administration Systems and

Biostatistics Activity (PASBA): http://

www.pasba.amedd.army.mil/

U.S. Army Center for Health Promotion

and Preventive Medicine (USACHPPM):

http://chppm-www.apgea.army.mil/

TRICARE Operations Center (TOC) TRICARE Operations Center (TOC):

The TOC provides access to the Template

Analysis Tool and enrollment and other

TRICARE reports. It is designed primarily

for use by military medical staffs in the

day-to-day management of their

peacetime medical operations. See http://

www.tricare.osd.mil/tools.

Various MHS performance measures MHS performance measures

such as HEDIS© MTF report cards and

TMA Statistical Reports, many of which

have MTF-level data, can be accessed at

http://www.tricare.osd.mil/reptcard/

mhssperf.html.

MHS data quality measures MHS data quality measures are

linked at http://www.tricare.osd.mil/

dataquality/reports.htm.

Health Care Survey of DoD Benefi- Health Care Survey of DoD Beneficiaries (HCSDB) ciaries (HCSDB): ciaries (HCSDB) Conducted annually

since 1995 and sponsored by the

TRICARE Management Activity, the

HCSDB is a mail survey of a representative sample of MHS beneficiaries investigating opinions regarding their health

status, use of health services focusing

particularly on preventive health services,

sources of health care, health insurance

coverage, satisfaction with health care

provided by military and civilian

facilities, access to health care, and their

knowledge and understanding of

TRICARE. Responses from the survey

provide a comprehensive look at how

military beneficiaries view their health

care. Results of the surveys and explanations of methods and results are available

at http://www.tricare.osd.mil/survey/

hcsurvey/default.htm.

Private Sector Care Reports Private Sector Care Reports: These

reports, when used in conjunction with

other internal patient management

reports (e.g., ADS and referral reports),

will help MTFs identify the types and

amounts of services provided to their

enrollees by providers in the private sector.

The reports that are currently available

have been formatted to assist in targeting

inpatient and outpatient workload for

recapture to MTFs. Aggregate and MTFspecific reports can be accessed at http://

199.208.1.220.

Utilization Review (UR) Utilization Review (UR): Utilization

review is not abandoned in the PHI

model, but remains a valuable tool to

scrutinize undesirable outcomes and

trends that warrant further analysis and

action to maximize quality and efficiency

and ensure limited resources are appropriately utilized. But the best way to

manage utilization is to manage health;

thus the health care system should focus

first on prevention, health promotion,

and condition management, and

implement appropriate utilization review

activities when outcomes indicate an

opportunity for improvement. Guidelines

for utilization management and utilization review are in the OASD (HA) Policy:

Revised Utilization Management Policy

for the Direct Care System (http://

tricare.osd.mil/policy/fy98/

umpd9831.html).

References

Hopkins, DP, et al. 2001. Reviews of

evidence regarding interventions to

reduce tobacco use and exposure to

environmental tobacco smoke. American

Journal of Preventive Medicine

20(2S):16-66. Available at http://

www.thecommunityguide.org/.

Rohrer JE. 1999. Planning for Community-Oriented Health Systems. Washington, DC: American Public Health Association.
72
73

Regional Population

Health Offices

Concept

Regional Lead Agent population health

offices should directly support population

health activities at MTFs and by Managed

Care Support Contractors and serve to

coordinate MTF and Managed Care

Support Contractor activities with MHS

and Service Headquarters offices and

programs that affect population health

and optimization.

Functions

Support MTF population health

activities

Within a Region, MTF and Managed Care

Support Contractor activities can be

coordinated to effectively and efficiently

utilize resources and achieve mission

success. Regional Lead Agent population

health offices can interact with MTFs in

the Region and Managed Care Support

Contractors to identify common issues in

geographically defined populations and

facilitate the development of local

solutions. Similarly, Regional Lead Agent

population health offices can analyze

resource and policy issues in these

populations and support MTFs and

Managed Care Support Contractors in

developing and deploying solutions.

Actionable information to MTFs

One of the most powerful functions of

Regional Lead Agent population health

offices is to develop, synthesize, and

disseminate actionable information on

the health status and health service needs

of specific populations within their

jurisdiction. By providing actionable

information to the accountable MTFs,

there will be clarity in regard to preventive services, condition/disease/case

management, data administration, and

other tasks required to improve the health

status of the population. In response to

needs of MHS enterprise and MTFs, the

Regional Lead Agent population health

office may extract and analyze population health data or may use existing or

future capability in various Service and

MHS agencies to develop population

health information (see MHS Support

Center). Regional Lead Agent population

health offices can serve the equally

important functions of identifying health

information needs for the Region and its

MTFs, disseminating and interpreting

relevant information, and assuring that

appropriate action is taken.

The Regional Lead Agent population

health office also will function to

establish clinical regions wherein two or

more MTFs’ populations overlap and the

MTFs share clinical capacity in providing

comprehensive primary and specialty

services to these populations. Such

overlapping populations create a unit of

analysis for population health that is

larger than the MTFs but smaller than

the geographic region. Two commonly

sited examples of areas where discrete

military populations access multiple

MTFs for care are the Seattle-Tacoma

area in Region 11 and San Antonio in

Region 6. In areas like these, health

service needs of enrollees should be

considered not only by each MTF, but also

by analyzing and aligning resources and

health information among the co-located

MTFs that act as a clinical region.

Clinical regions that integrate delivery

systems for population health become

effective and efficient.

Support reporting to enterprise

Regional Lead Agent population health

offices can serve another important

function by developing Region-level

population health data that support the

Section V.
74

role-up or aggregate enterprise-level

metrics for decision support at the most

central offices of the MHS. This same

Region-level data can be used to compare

among Regions. Such inter-Region

comparisons facilitate benchmarking, a

driver of Region-level optimization and

population health improvement. These

comparisons also aid in identifying

opportunities to realign resources to

promote enterprise optimization.

Knowledge transfer

Regional Lead Agent population health

offices must support knowledge transfer

among MTFs, between Regions, and both

to MTFs from Headquarters and to

Headquarters from MTFs. Effective

sharing of lessons learned, whether good

or bad, is critical for the success of

population health improvement initiatives in the large, diverse, and complex

MHS.

Roles

Regional Lead Agent population health

offices should facilitate population health

working groups with within their Regions

with representatives from MTFs in the

Region. They will be invited to join the

planned MHS Population Health Work

Group. A list of Regional Lead Agent

office population health representatives

can be found at http://

www.tricare.osd.mil/opt_int/PHIT.htm.

The capabilities needed for Region

population health offices include

population health information management, workgroup coordination and

management, program management,

and health policy. The offices must have

expertise in health measure definition,

data extraction, analysis, and evaluation,

and information dissemination.
75

Military Health

System Optimization

& Population Health

Support Center

(OPHSC)

Concept

The OPHSC is currently under development. The following represents the

planned concept of operations.

The OPHSC will respond to information

and resource needs from all levels of the

MHS. Its scope includes facilitating and

supporting the development of MHS-wide

programs for optimization and population health improvement, including

population health educational programs

for patients, MTF personnel, and leadership. Ultimately, it will proactively

research and disseminate information to

support performance improvement across

the enterprise. Until the MHS OPHSC is

fully operational, questions and comments about the principles, processes,

tools and resources in the PHI Plan and

Guide can be communicated to the

contacts at http://www.tricare.osd.mil/

opt_int/PHIT_Member.htm.

The OPHSC will provide a single interface

to the customer for supporting and

implementing the programs, tools, and

surveillance systems designed to measure

and improve the health of MHS beneficiaries. It will integrate a number of

currently separate, but related, population

health data, surveillance, and program

management activities. Efficiencies are

to be achieved by consolidating and

reducing administrative and IM/IT

support, eliminating duplicative missions

and functions, and ensuring that the

various MHS population health programs

and tools operate together seamlessly.

While the OPHSC will provide feedback

and recommendations to higher authorities for planning, research, and policy

development, its primary mission will be

program execution and field support. To

achieve this mission, it will work closely

with other population health agencies

(e.g., DoD Pharmaco-Economic Center

[PEC], U.S. Army Center for Health

Promotion and Preventive Medicine

[CHPPM], the USAF Population Health

Support Division [PHSD], USAF Institute

for Environmental, Safety, and Occupational Health Risk Analysis [IERA], Navy

Environmental Health Center [NEHC],

Uniformed Services University of Health

Sciences [USUHS], and TMA, among

many others) operating within the MHS.

Activities supporting a total community

approach to population health will be

added to the MHS OPHSC after initial

stand-up.

Functions

Knowledge Management and

Transfer

The OPHSC will provide centralized

population health program support to the

MTF staff (primary customer), MCS

contractors, Service intermediate

commands, Regional Lead Agent offices,

and the Service Surgeons General. It will

maintain a central clearinghouse for

population health knowledge. It will

make available information on current

programs, policies, and points of contact

for population health and optimization

activities across the MHS. The Center will

also collect and share population health

and optimization innovations. These

functions will be accomplished through a

web-page and by telephone access to

OPHSC personnel.

The OPHSC will provide essential support

for the Population Health Improvement

Plan by:

 Identifying, evaluating and disseminating clinical and business tools,

Section VI.
76

 Operating a robust information

center,

 Procuring and disseminating

population health and condition and

disease management tools, and

 Assisting MTFs with health data and

information needs (turning data

into information).

Primary activities will include:

1. Operating a centralized help desk

(three-tiered) as a single entry point

of service to assist MTF commanders

and staff in implementing best

clinical and business practices, to

most effectively and efficiently meet

the needs of beneficiaries.

a) Tier one – telephone/e-mail/Webbased resource support

b) Tier two – research and networking

support

c) Tier three – on-site support for

training and implementation

guidance

2. Assisting MTFs in selecting the best

implementation strategies for their

installation.

3. Assisting MHS leadership and DoDlevel policy-makers responsible for

making evidence-based,

population-health management

decisions, by accessing or centrally

acquiring (when necessary) pertinent data, analyzing and interpreting the data, and providing timely

recommendations. Relevant

information will be “pushed,” via

Web-based technology and other

electronic means to MTFs, Regional

Lead Agent offices, Service intermediate commands, and higher headquarters.

4. Providing functional input to the

MHS IM/IT communities

a) Facilitating centralized MHS data

collection, maintenance, analysis,

and reporting for HEAR 1.0/2.0,

immunization tracking, and PPIP.

b) Serving as the coordination center

for health-surveillance systems (in

garrison and during deployment).

c) Facilitating development and

implementation of methodologies

that improve MHS population-health

data quality.

Support for Regional Lead Agent

Population Health Offices

The MHS OPHSC will facilitate the MHS

Population Health Work Group comprised of representatives from each

Region. It will cascade relevant information and issues through Regional Lead

Agent and Service intermediate command

population health offices to MTFs. It will

also collect, analyze and evaluate issues

Figure 12. Integrating and Coordinating Enterprise Population Health Improvement Support Capacity Figure 12. Integrating and Coordinating Enterprise Population Health Improvement Support Capacity
77

from Region and intermediate command

offices for communication to MHS and

Service leadership.

Program Management

The OPHSC will integrate or coordinate

many of the programs aimed at improving the delivery of preventive services and

the management of clinical and disease

conditions. Examples of existing

programs to develop or implement tools

for MHS-wide use include Self-Reporting

Tools/Health Evaluation Assessment

Review (HEAR), Put Prevention Into

Practice (PPIP), VHA/DoD Clinical

Practice Guidelines (CPG), and disease

and condition management. Integrating

and coordinating these and future

programs will require OPHSC to perform

several functions:

1. Establishing a centralized activity for

selecting, adapting, coordinating,

implementing, and sustaining tools

and resources throughout the MHS;

2. Assuring compliance with programs

and recommendations of the

Prevention, Safety, and Health

Promotion Council (PSHPC);

3. Coordinating with ASD/HA, TMA,

and Surgeons General regarding

policy;

4. Planning, budgeting, and monitoring program activities;

5. Developing the infrastructure to

identify and adapt interventions and

tools, identify outcomes, measure

change, and sustain program

development;

6. Providing consultation to Regional

Lead Agent offices, MTFs, Services,

Service intermediate commands,

Managed Care Support Contractors,

and others;

7. Documenting and aggregating needs

from the field;

8. Coordinating and partnering with

newly developing MHS “Centers of

Excellence” and other benchmark

organizations and leveraging their

lessons learned, innovations,

marketing strategies, and education/

training capabilities.

Patient and Staff Education

Changing individual behavior is difficult

at best. The majority of medical conditions seen today are a result of unhealthy

lifestyle choices. Patient education is

essential to modifying risk factors that

adversely impact health. Clinical reengineering and local implementation of

population health improvement efforts

require just-in-time education of clinical

personnel in condition/disease management, patient education, and health care

integration skills. Activities include:

1. Evaluating the effectiveness of

existing officer and enlisted training

in teaching principles of population

health;

2. Identifying assessment tools to

measure knowledge, attitudes, and

skills of health-care workers in

population health;

3. Identifying and implementing, in

cooperation with Service education

and training agencies, required

pipeline and just-in-time training

courses in population health,

disease/condition management, and

other topics, as required;

4. Providing MTF decision support

personnel with central and on-site

training in all aspects of population

health as needed to develop local

expertise, possibly using the trainthe-trainer approach;

5. Utilizing web-based technology to

provide distance learning in selected

population health areas; develop a

library of courses as the needs are

identified.

Performance Improvement:

Actionable Information to Regions and MTFs

Finally, the OPHSC will ensure that health

status and performance measurement

reports are disseminated to Regional Lead

Agent offices and MTFs for their enrolled

populations. By coordinating many of

the population-health data collection,

analysis, and reporting functions, the

OPHSC will help track trends in population health status, health risks, preventive

services delivery, utilization, reportable

diseases, occupational injuries and

illnesses, etc.

Once developed and approved, specific

condition and disease management

outcomes will also be tracked and

reported. The OPHSC will provide

recommendations for policy development, research and special studies and

program refinement, based on continuous monitoring of the various population

health data sources. Activities will

include:

1. Facilitating development of Provider

Support Reports (PSR) to enhance

the health-care delivery process;

training local staff in this process as

needed for local data access;

2. Coordinating IM/IT development

and data issues;

3. Coordinating clinical practice

improvement strategy development

through integration of research and

development programs within the

MHS, to include demonstration

projects and automation implementation endeavors in support of

clinical practice (i.e. DoD/VA CPG
78

IPT);

4. Providing periodic updates to MTFs

regarding data trends, metrics

improvements, systems requirements, program changes, and

related issues;

5. Monitoring the health care environment for performance improvements

and best clinical practices for

dissemination across the MHS;

6. Facilitating and supporting the

development of population health

marketing strategies;

7. Identifying education and training

requirements for new population

health programs, tools, or initiatives,

in coordination with education/

training agencies for each Service;

facilitating central just-in-time

training programs on population

health, as needed;

8. Evaluating health services delivery

systems within DoD and the civilian

sectors to identify opportunities for

system optimization within the MHS;

and

9. Consulting for questions/concerns

from MTFs and intermediate

commands regarding expanding the

roles of nurses, enlisted medical

personnel, and other ancillary

services personnel so they may

function at the optimal level within

their scope of practice.

Enterprise-wide Health Improvement Capacity

There is a great capacity in the MHS to

support population health improvement

and optimization activities described in

this plan. This capacity is distributed

among numerous offices in Headquarters, Regional Lead Agent offices, and

other offices. Figure 12 displays some of

the offices where this great capacity

resides. A challenging function for the

OPHSC is to facilitate integrating and

coordinating the capacity across the

enterprise to get the best health outcomes

for the entire MHS beneficiary population.
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Tables of Population

Health Key Process

Element Tools

Section VII.

Key Process Element 1. Identify the population 

TOOLS 

TITLE / DESCRIPTION CONTACT 

National Enrollment Database (NED) http://www.tricare.osd.mil/pmo/programs/programs_main.html

Primary Care Manager By Name (PCMBN) HA Policy: http://www.tricare.osd.mil/policy/ha00pol/clin00_001.html

Health Evaluation Assessment Review (HEAR) HA Policy: http://tricare/policy/fy97/hear9703.html

Implementation information is available under tools at https://phsd.afms.mil/phso/. 

Population Health Operational Tracking and 

Optimization (PHOTO) 

http://photo.tma.osd.mil 

Survey of Health Related Behaviors http://www.tricare.osd.mil/tricaresurveys/surveys01.htm 

All-Region Server (ARS) Bridge http://www.eids.ha.osd.mil

Defense Medical Surveillance System (DMSS) http://www.amsa.army.mil

Air Force Assistance With Enrollment Air Force enrollment support available under tools at https://phsd.afms.mil/phso/. 

Key Process Element 2. Forecast Demand 

TOOLS 

TITLE / DESCRIPTION CONTACT 

Health Evaluation Assessment Review (HEAR) HA Policy: http://tricare/policy/fy97/hear9703.html

Implementation information is available under tools at https://phsd.afms.mil/phso/. 

Utilization Review (UR) HA Policy and Guide: http://tricare.osd.mil/policy/fy98/umpd9831.html

Air Force forecasting Tool https://phsd.afms.mil/phso

Navy Population Health Navigator Navy personnel should contact NMIMC regarding the Population Health Navigator (CDR Mark Turner at 

mailto:mdturner@us.med.navy.mil). 

Managed Care Forecasting and Analysis System 

(MCFAS) 

http://www.eids.ha.osd.mil

Healthcare Complex Model Contact service representative at: http://www.tricare.osd.mil/opt_int/PHIT_Member.htm

All-Region Server (ARS) Bridge http://www.eids.ha.osd.mil
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Key Process Element 3. Manage Demand 

TOOLS 

TITLE / DESCRIPTION CONTACT 

Telephone Advice HA Policy: http://www.tricare.osd.mil/policy/fy97/hcil9749.html

Put Prevention Into Practice (PPIP) HA Policy: http://www.tricare.osd.mil/policy/fy98/ppip9827.html

Implementation information: http://www.ahcpr.gov/clinic/ppipix.htm

Air Force Population Health Data CD https://phsd.afms.mil/phso/

Navy Population Health Navigator Navy personnel should contact NMIMC regarding the Population Health Navigator (CDR Mark Turner at 

mailto:mdturner@us.med.navy.mil). 

Health Evaluation Assessment Review (HEAR) HA Policy: http://tricare/policy/fy97/hear9703.html

Implementation information is available under tools at https://phsd.afms.mil/phso/. 

Key Process Element 4. Manage Capacity 

TOOLS 

TITLE / DESCRIPTION CONTACT 

Template Analysis Tool (TAT) http://www.tricare.osd.mil/tools

Navy tools Available through: https://bumed.med.navy.mil/med03/tools/default.asp

Air Force tools Available through: https://phsd.afms.mil/phso/

Health Care Reengineering http://www.tricare.osd.mil/hcr

Primary Care Manager, By Name (PCMBN) HA Policy: http://www.tricare.osd.mil/policy/ha00pol/clin00_001.html

DOD/VA Clinical Practice Guidelines (CPGs) http://www.cs.amedd.army.mil/qmo/Home.htm
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Key Process Element 5. Evidence-Based Primary, Secondary, and Tertiary Prevention 

TOOLS 

TITLE / DESCRIPTION CONTACT 

Health Promotion Army: http://chppm-www.apgea.army.mil/dhpw

Navy: http://www-nehc.med.navy.mil/hp/index.htm

Air Force: https://www.afms.mil/op_prev/hlthprom.cfm

Evidence-Based Medicine http://cebm.jr2.ox.ac.uk

Put Prevention Into Practice (PPIP) HA Policy: http://www.tricare.osd.mil/policy/fy98/ppip9827.html

Clinicians Handbook: http://www.odphp.osophs.dhhs.gov/pubs/guidecps/

Army program: http://chppm-www.apgea.army.mil/dhpw

Navy program: http://www-nehc.med.navy.mil/hp/index.htm

Air Force program: https://phsd.afms.mil/phso/

DOD/VA Clinical Practice Guidelines (CPGs) http://www.cs.amedd.army.mil/qmo/Home.htm

Army implementation: http://www.cs.amedd.army.mil/qmo/Home.htm

Navy implementation: https://bumed.med.navy.mil/med03/ebm

Air Force implementation: https://phsd.afms.mil/phso/

National Guidelines Clearinghouse http://www.guidelines.gov

Key Process Element 6. Community Outreach 

TOOLS 

TITLE / DESCRIPTION CONTACT 

Healthy People 2010 http://www.health.gov/healthypeople/

Guide to Community Preventive Services http://www.thecommunityguide.org

Air Force Health and Wellness Centers http://www.afms.mil/op_prev/hlthprom.cfm 

Air Force Family Advocacy http://www.afms.mil/com_prev
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Key Process Element 7. Analyze Performance and Health Status 

TOOLS 

TITLE / DESCRITION CONTACT 

Population Health Operational Tracking and 

Optimization 

http://photo.tma.osd.mil/ 

TRICARE Operational Performance Statement 

(TOPS) 

http://www.tricare.osd.mil/reptcard/tops/topsrept.html

DOD/VA CPG’s http://www.cs.amedd.army.mil/qmo/Home.htm

Air Force Metrics http://p2r2va.tma.osd.mil

Air Force quarterly MTF data products https://phsd.afms.mil/phso/

Population Health Navigator Navy personnel should contact NMIMC (http://navmedinfo.med.navy.mil/) regarding the Population Health 

Navigator (CDR Mark Turner at mailto:mdturner@us.med.navy.mil). 

Army Medical Information Management products Patient Administration Systems and Biostatistics Activity (PASBA): http://www.pasba.amedd.army.mil/

U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM): http://chppmwww.apgea.army.mil/

TRICARE Operations Center (TOC) http://www.tricare.osd.mil/tools.
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