Q and A with Lt. Gen (Dr.) Charles B. Green Published Nov. 2, 2010 WASHINGTON -- This interview with the AF/SG appeared in the September/October 2010 edition of SERGEANTS Magazine. It appears here with the publisher's permission. Q. How is the Air Force medical community bridging medical treatment for all Airmen? How does the Air Force "team" with the Department of Veterans Affairs? Over the last 18 months, the Air Force has implemented a new process that more efficiently transfers Service medical and dental treatment records from the active duty military treatment facility (MTF) or Reserve Component (RC) medical unit to the VA. This process applies to Airmen retiring, separating, and being discharged. This new process requires all entries from the DOD electronic health record be printed and added to the paper record before the records are transferred to one central Air Force health records disposition center at Randolph AFB, Texas. The central records disposition center verifies all required medical and dental records (if available) have been obtained, documented as received, and mailed to either the VA regional office processing the Airman's VA disability claim or to the VA's Records Management Center in St Louis, Mo. VA records managers now only have to interact with one central Air Force medical records center instead of almost 130 Air Force active duty MTFs and RC medical units. Performance metrics indicate the new process is working. The Air Force Disability Evaluation System (DES) evaluates all cases where an Airman has a condition that is disqualifying for continued service in accordance with Air Force Instruction (AFI) 48-123, Medical Examinations and Standards. A fitness-for-duty determination is conducted at the local MTF. Airmen who may be retainable despite chronic medical conditions are further reviewed by the Air Force Personnel Center medical and personnel professionals. When conditions allow, Airmen are retained. Airmen with medical conditions rendering them unfit for retention or continued duty are referred into the Disability Evaluation System by the MTF. Through the DoD-VA Disability Evaluation System Pilot program, servicemembers receive a single disability review and rating prior to the beginning of a Medical Evaluation Board (MEB). Before the VA review, the participating MTF is required to provide the VA with a copy of the member's complete health record. This new program offers a unique opportunity for the VA to medically evaluate members and determine their disability ratings before they meet an MEB. The complexity of the DES process depends greatly on an Airman's medical conditions. The goal in all cases is to complete a thorough medical evaluation and provide an appropriate disposition. When an Airman must transition from military health care to the VA system, this new process helps assure continuity of medical care for our warriors. Our long history of collaborating with the Veterans Administration (VA) also enhances clinical currency for our providers, saves valuable resources, and provides a more seamless transition for our Airmen as they move from active duty to veteran status. The Air Force currently has five joint ventures with the VA, including the most recent at Keesler AFB, MS. Additional efforts are underway for Buckley AFB, CO, to share space with the Denver VA Medical Center, which is now under construction. Q. The Air Force's successes in past years in preventing suicides have been remarkable. What leadership tools does the Air Force employ today to reduce its suicide rate? The Air Force implemented a reengineered suicide prevention program in 1997, which has been nationally recognized for its effectiveness and as a model of intervention. Yet our work here is never done and we have experienced a slowly increasing rate of suicide since 2007. The Air Force held a Wingman Day in May to re-focus attention on prevention. We are also enhancing our prevention programs to further decrease suicides by targeting those most stressed by high operations tempo. We now target more in-depth interventions and training to Air Force security forces and intelligence career fields, whom we have identified as having nearly double the incidence of suicide compared to the rest of the Air Force. The Air Force continues training the entire force on suicide prevention and coping skills to improve both Airman and family resilience. We have fielded "Frontline Supervisor Training" courses to better prepare supervisors to engage with their Airmen and address risk factors for suicide. We adapted new concepts such as 'Ask, Care and Escort,' and collaborative care, wherein mental health providers are now embedded in the majority of our family health clinics. Collaborative care, on-line help, mandatory post-deployment surveys and Family Life counselors at our Airman and Family Readiness Centers have decreased stigma and allow those in need to get help earlier. Ultimately our suicide prevention efforts relies on all AF personnel to be aware of the warning signs for suicide and to have the courage to reach out to those around them and ask about suicide when they see those signs. The Air Force has worked closely with DOD in establishing the Suicide Prevention and Risk Reduction Committee (SPARRC), which provides a forum for sharing of practices across the Services. The SPARRC has been instrumental in establishing consistent data collection processes across the Services, as well as standardizing the reporting of suicides. The SPARCC meets on a monthly basis to facilitate communication across DOD agencies and the Services regarding efforts underway in suicide prevention programs. DOD recently took part in a Congressional Task Force on Suicide Prevention comprehensive review of suicide prevention efforts in DOD. The Air Force suicide prevention program and the SPARRC stand ready to respond to findings and recommendations from this task force. The SPARRC provides oversight, and coordinates with the Department of Veterans Affairs and civilian agencies, on the annual DOD suicide prevention conference, which fosters sharing of best practices across the country. Q: Resiliency is the new buzzword in the mental health arena...what is the Air Force doing to sustain Airman resiliency? Resiliency is a broad term that describes the set of skills and qualities that enable Airmen to overcome adversity, and to learn and grow from experiences. It is a complex concept encompassing physical, mental, spiritual, and social health. Physical health is critical because peak fitness enables increased resilience. This is part of the rationale behind the increased frequency of physical fitness testing. Social health enables resilience; being connected to others provides a sense of 'belonging' and that promotes healthy adjustment. Spiritual health is another important focus, with a sense of purpose being a defining characteristic of resiliency. Finally, mental health supports resiliency because a mentally healthy individual has better coping resources and flexibility in facing adversity. We are working closely with the AF resiliency lead, the Manpower and Personnel Directorate (A1), in formulating approaches to maximize resilience across the Air Force. In the past, we focused on what was wrong with Airmen who were not coping with adverse events. Resiliency shifts to a prevention focus - we should be looking at the individuals who have been through adversity and learn from them the skills that enabled them to succeed. Distilling those skills and teaching them will lead to a healthier force. Rather than applying all services to all Airmen, the Air Force has adopted a targeted training approach, realizing there are Airmen in different situations with different levels of resiliency. We visualize the model in the form of a pyramid. The bottom level of the pyramid is fundamental and applies to everyone. We foresee implementing resiliency concepts into all accession training to ensure the presence of basic skills from the beginning of an Airman's enlistment. The second level of the pyramid targets Airmen who are deploying or who otherwise are in higher risk groups. Airman Resilience Training is provided both pre-and post-deployment, and covers important skills like critical thinking, situational awareness, and controlling emotional and behavioral reactions. At the top of the pyramid are groups that have high frequency of exposure to battle. This level includes initiatives like the Deployment Transition Center (DTC) at Ramstein AB, Germany. The DTC opened in July and provides a two-day reintegration program en route from the AOR for people who have higher exposure to combat "outside the wire." The DTC uses chaplain, mental health, and peer facilitators from a redeployer's career field. These facilitators foster discussion in groups of redeployers who meet to place the deployed experience in context. The DTC provides training, not treatment, and it isn't documented in members' medical records. It is focused training for reintegration into work and family. Feedback has been overwhelmingly positive. In addition to this broader Air Force approach, some Air Force communities are pursuing their own resiliency initiatives. ACC and AMC have begun to use a model termed "Comprehensive Airman Fitness," modeled from the Army's "Comprehensive Soldier Fitness" that uses features of positive psychology to enhance resiliency skills. Master Resiliency Trainers are trained at the University of Pennsylvania and then take that training to their bases for dissemination. Mortuary Affairs at Dover AFB, where casualties from OIF and OEF are readied for burial, has a highly structured resiliency program in place that integrates command and helping agencies in ensuring physical, spiritual, social, and mental health. That model is being implemented for medics in Bagram and Balad, where the level of mortality and morbidity are much higher than most medics ever see in their home station MTFs. There are multiple research initiatives ongoing with the goal of evaluating how best to train high combat exposure groups for the adversity they face downrange. Q. What is the Air Force Medical Service doing to ensure success in delivering medical care to Airmen and their family members? We are upgrading our medical facilities and rebuilding our capabilities to give patients more choice and increase provider satisfaction with a more complex case load. In our larger facilities, we launched the Surgical Optimization Initiative, which includes process improvement evaluations to improve operating room efficiency, enhance surgical teamwork, and eliminate waste and redundancy. This initiative resulted in a 30 percent increase in operative cases at Elmendorf AFB, Alaska, and 118 percent increase in neurosurgery at Travis AFB, California. We are engaged in an extensive modernization of Wright-Patterson Air Force Base Medical Center in Ohio with particular focus on surgical care and mental health services. We are continuing investment in a state-of-the-art new medical campus for the San Antonio Military Medical Center (SAMMC) at Lackland AFB, Texas. Our ambulatory care center at Andrews AFB, Md., will provide a key capability for the delivery of world-class health care in the National Capital Region's multi-service market. By increasing volume, complexity and diversity of care provided in Air Force hospitals, we make more care available to our patients; and we provide our clinicians with a robust clinical practice to ensure they are prepared for deployed operations, humanitarian assistance, and disaster response. Our patients appropriately expect AFMS facilities and equipment will be state-of-the art and our medical teams clinically current. They trust we will give them the best care possible...and our goal is to earn that trust every day. Q. The AFMS has recently implemented the Family Health Initiative (FHI) - what is it and will it improve the delivery of medical care to Airmen and their families? To achieve better health outcomes for our patients, we implemented the Family Health Initiative (FHI), which mirrors the American Academy of Family Physicians' "Patient Centered Medical Home" concept, and is built on the team-approach for effective care delivery. The partnership between our patients and their health care teams is critical to create better health and better care via improved continuity, and reduce per capita cost. For example, Disease Management Programs are estimated to save $685-950/year per patient. Hill AFB, Utah, showed an improvement in glycemic control with 62 percent of the diabetic population for a potential savings of $221-$306K per year. Our providers are given full clinical oversight of their care teams and are expected to practice to the full scope of their training. We believe the results will be high quality care and improved professional satisfaction. Two of our pilot sites, Edwards AFB, Calif., and Ellsworth AFB, S.D., have dramatically improved their national standings in continuity, quality, access to care, and patient satisfaction. Eleven other bases are implementing Medical Home, with an additional 20 bases scheduled to come on-line this year. Q. What significant improvements will Air Force enlisted medical servicemembers see in the coming years in regards to indoctrination, certifications, and unified medical service training (Air Force medical training resources were recently relocated to Fort Sam Houston) as an example)? The Medical Education and Training Campus (METC) in San Antonio will serve as the birthplace for Joint interoperability for corpsmen, medics and technicians. In five years, every medic and corpsman under the grade of E-5 will have been educated at METC. METC is an integrated campus under a single university-style administration, with more than 100 courses available to students. METC entered into its initial operating capability June 30. Its initial training course, Radiography Specialist, began in April. Other courses will be phased in throughout the rest of the year and into 2011. The campus will have more than 24,500 students going through its doors each year, with an average daily student load of approximately 8,000. METC officials will also employ an operating staff and faculty of more than 1,400. By service, the student breakdown includes approximately 45 percent Army, 31 percent Navy and 24 percent Air Force. The longest program offered is cytology, which is the study of cells, at 52 weeks; and the shortest, at four weeks, is patient administration. METC is more than an institution of higher learning. This will become a platform of medical diplomacy on the world stage. Nations across the globe will send their men and women to this campus because METC stands for the best platform the world has even known for producing medics and corpsmen. Q. Under current BRAC Joint Basing initiatives, what will the medical services see as an impact of working in a joint environment? Operating in a Joint environment is nothing new for Air Force medics. We have always been Joint, whether with our Sister Services or coalition partners. A key example of how this Jointness is expanding occurred as a result of BRAC 2005, which recommended the consolidation of Wilford Hall Medical Center (WHMC) and Brooke Army Medical Center (BAMC) in San Antonio into one medical region with two integrated campuses known as San Antonio Military Medical Center (SAMMC). Brooke Army Medical Center will become the inpatient tertiary care center providing all inpatient care as well as all trauma and emergency medical care. The facility will be known as SAMMC - North. Wilford Hall Medical Center will be converted into a large ambulatory care center, SAMMC - South. Beyond that - also a result of BRAC 2005 -- in 2011 we will begin moving to our much-anticipated colocated Medical Headquarters in Falls Church, Va. The new site will colocate staffs of the Office of the Secretary of Defense (Health Affairs), TRICARE Management Activity, Office of The Surgeon General and U.S. Army Medical Command, Office of the Surgeon General of the Air Force to include the Air Force Medical Support Agency, and the Navy Bureau of Medicine. Those personnel located at the Pentagon are not affected. The Assistant Secretary of Defense for Health Affairs, the Deputy Surgeons General, and the Deputy Director of TRICARE Management Activity are actively involved, and formed a senior-level team that has been working for the past year to ensure a smooth transition occurs. We are all committed to providing timely and accurate information to all government staff, contractor partners and on-site personnel who support our critical missions. Although we certainly realize that bringing more than 3,000 staff together under one roof presents many logistical challenges, we are acquiring the support of a highly qualified company to assist us with the move and outfitting of the new site. Per BRAC law, the move will be completed by Sept. 15, 2011. Together we look forward to greater synergy in meeting the healthcare needs of our 9.6 million beneficiaries.