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Air Force Medical Home

What is Air Force Medical Home?

Air Force Medical Home is transforming the way the Air Force Medical Service delivers health care, having a positive impact on the overall patient experience. Today, most patient interactions happen within one of more than 230 Air Force Medical Home clinics where medical Airmen and Guardians care for more than 1.1 million patients.

Primary care managers serve as an entry point into the military health care system and are helping to remove barriers to specialty providers. Research indicates that patients in medical home-style clinics make fewer trips to the emergency room and have fewer overall hospitalizations. This helps the Air Force Medical Service meet its goals of a better patient experience for our Airmen, Guardians, their families and retirees.

Critical Role of Air Force Medical Home

The vast majority of Air Force medicine is executed in Air Force Medical Home clinics. There are more than 230 Air Force Medical Home clinics. These clinics provide Trusted Care to more than 1.1 million patients.

Air Force Medical Home History

The American Academy of Pediatrics established the first Medical Home concept as early as 1967. In 2001, the Air Force introduced the Primary Care Optimization model. Beginning in 2007, this involved primary care organizations coming together to release the Joint Principles of Patient-Centered Medical Home.

The Air Force Medical Home builds on existing Patient-Centered Medical Homes to transform base-level healthcare delivery from a model designed to maximize visits. With a focus on improving health and performance, commanders are enabled to accomplish missions, with patients achieving their health goals.

Graphic of the Air Force Medical Home Timeline

Seven Core Principles of Air Force Medical Home

* Trusted Care: Respect for people, a duty to speak up, and a commitment to resilience. Every Airman, every day, a problem solver.

* Personal Provider: Dynamic, trusted, respectful and enduring relationships between individuals, families, and their clinical team members are hallmarks of primary care.

* Patient-Centered: The patient is a whole person, with care focusing on physical, emotional, psychological, and spiritual well-being, as well as cultural, linguistic, and social.

* Comprehensive: Tailored to meet the needs of each patients and family members, including acute, chronic and preventive care, behavioral and mental health, and health promotion.

* Coordinated: Care is organized across all elements of the broader health care system, with a focus on transitions of care between these systems.

* Accessible: Patients are able to access services with shorter waiting times, after hours care, and electronic or telephone access, 24 hours a day, seven days a week.

* Mission Sustaining: To ensure medically-ready Airmen and Guardians who are well-equipped, both physically and mentally, to support full spectrum military operations across the globe.

Focus Areas

Improved Patient Portal

TRICARE Online received a significant update, with patients are now able to:

* Book appointments online, any time

* Set up text and email appointment reminders

* Cancel appointments

* Review laboratory and radiology results

* Refill prescriptions

* Access Secure Messaging

Enhanced Access Team

Through a team-based approach to health care, specialty providers, mental health experts, physical therapists, clinical pharmacists, social workers, and others are embedded into primary care clinics to work closely together and deliver trusted care for each patient. This has proven instrumental in removing barriers to health care and driving efficiencies within medical facilities.

Goal: Right care, right provider, right time, right venue

Behavioral Health Optimization Program includes:

* Internal Behavioral Health Consultant

* Behavioral Health Care Facilitator

Embedded clinical pharmacists collaborate with teams to:

* Transition care management

* Complete comprehensive medication reviews

* Provide medication management and consultation

* Provide polypharmacy coordination

* Educated patients

Goals of embedded clinical pharmacists include:

* Improving medication-related health outcomes

* Reducing adverse drug reactions and medication errors

* Decreasing complications and hospital admissions

* Improving care, access, patient, and staff satisfaction

The prototype of an effective Enhanced Access Team Member includes:

* 3000-7499 adults enrolled to PCCs that earn Internal Behavioral Health Consultant provider

* The Behavioral Health Optimization Program, which is a tool to address the challenges of changing health behaviors to produce better medical outcomes

* A minimum of 400 encounters quarterly

Functions include:

* Newly diagnosed chronic disease and compliance issues

* Sleep disturbance, parenting stress, work issues

* Lifestyle change and health risk factors (e.g. smoking and weight loss)

* Chronic pain (e.g. headache, back pain, fibromyalgia)

* Mental disorders (e.g. depression, anxiety, panic d/o)

Impact creates:

* Better care and outcomes

* Access

* Care coordination

Please note, some military treatment facilities have started providing direct access to physical therapy for active duty personnel with acute musculoskeletal complaints.

Other members based on local availability include:

* Medical nutrition therapists

* Nurse educators

* Exercise physiologists

* Chiropractic services

Behavioral Health Optimization Program

The purpose of the Behavioral Health Optimization Program is to work with patients and their primary care manager’s team to identify, assess, and manage medical and behavioral health conditions, and to link patients to needed resources.

Almost every human condition has a behavioral component and some of the most frequently treated conditions include:

* Sleep

* Pain

* Sadness

* Stress and anxiety

* Relationship challenges

* Medical conditions (e.g., diabetes)

* Smoking cessation

* Goal setting

* Activity scheduling

* Memory

Internal Behavioral Health Consultant: IBHCs can be either a social worker or a psychologists. The IBHC works with the primary care managers in situations where good health care involves paying attention to physical health, habits, behaviors, emotions, and how they interact.

Anytime the primary care team and the patient decide that medical care could be enhanced by consulting with a behavioral scientist the IBHC may be asked to contribute to the care.

Typical Patient Visits with IBHC: A typical visit is about 25 minutes and the IBHC will ask several questions about your health, and then together, you and the IBHC will come up with a plan. The plan could involve reading materials or practicing skills on your own and following up with the PCM's team or coming back to see the IBHC for another two or three appointments.

If you and the IBHC think a specialty care is the best option, the IBHC can help with the referral. The IBHC will write the plan in your medical record and share with your PCM after the appointment.

Behavioral Healthcare Facilitator: The BHCF is generally a registered nurse in the Patient-Centered Medical Home who has been trained to help patients experiencing depression, anxiety, and/or post-traumatic stress disorder. The BHCF supports the PCM by providing frequent contact with the patient to answer questions, encourage adherence to the treatment plan, and monitor treatment response. BHCFs provide feedback to the PCM through face-to-face communication, telephone, email, and through the electronic medical record.

Who should be working with a BHCF? Appropriate patients for care facilitation are adult patients with depression, anxiety or PTSD whose medication for depression, anxiety or PTSD is being managed by the PCM. Ideally, you will be referred for care facilitation as soon as a diagnosis is made and/or the medication started.

BHCFs have a structured set of interview questions related to the following:

* Medication adherence and side effects

* Behavioral health treatment adherence

* Creation and adherence to self-management goals (developed collaboratively)

* Response to treatment monitoring via assessment measures

Meeting Patient Demand

This includes:

* Empowering self-management

* Supporting the TRICARE Online Patient Portal

- Nurse Advice Line

- Secure Messaging

* Supporting the Behavioral Health Optimization Program

- Clinical Pharmacist

- Physical Therapist

- Medical Management Team

- Health Promotions

- Nutritionist

* Face-to-face appointments with the primary care manager

* Virtual appointments with the PCM and/or TCON, with Air Force Medical Home team)

* Supporting nurses and technicians

Supporting staff protocols