Managed Care Provider: Ensuring Health Care Services to All with a Need
Rear Admiral Nancy J. Lescavage
Regional Director
TRICARE Regional Office West
Rear Admiral Nancy J. Lescavage currently is assigned as the regional director of the TRICARE Regional Office West, San Diego, Calif., overseeing managed care support contracts and an integrated health care delivery system in 21 states covering more than 2,700,000 TRICARE eligible beneficiaries.
Lescavage recently served as the 20th Director of the Navy Nurse Corps and was the commander, Naval Medical Education and Training Command, Bethesda, Md. She hails from Port Carbon, Pa., and is a licensed nurse in that state. Her diploma in nursing is from Saint Joseph Hospital School of Nursing in Reading, Pa. She received a baccalaureate degree in nursing from the University of Maryland, a graduate degree from the University of Pennsylvania School of Nursing and a certificate in management from Wharton School of Business.
Receiving her commission in May 1972, Lescavage has held numerous senior executive leadership positions to include: assistant chief, Health Care Operations, Bureau of Medicine and Surgery (2001–2002); deputy assistant chief for Health Care Operations, Bureau of Medicine and Surgery (1999–2001); commanding officer, Naval Hospital, Corpus Christi, Texas (1997–1999); executive officer, Naval Hospital, Great Lakes, Ill. (1995–1997); and commanding officer, Fleet Hospital Five (1995–1997).
Additionally, she served as a Congressional Fellow in the office of United States Senator Daniel K. Inouye [D-Hawaii] (March 1993–January 1995). Quickly recognized as an authority on the legislative process and its application to health care, she provided critical liaison with the White House and health care task forces concerning National Health Care Reform issues. From August 1989 to March 1993, as a senior health facilities planner for the assistant secretary of defense (health affairs), Lescavage was responsible for the planning and design of military medical construction projects worldwide and for performing comprehensive health care and costbenefit analyses in support of Department of Defense initiatives.
Prior to her DoD assignments, she was in charge of the Recruit Medical Clinic at Recruit Training Command, Great Lakes, Ill. This clinic was responsible for providing medical care to approximately 40,000 recruits annually.
Other assignments include: National Naval Medical Center, Bethesda, Md.; Naval Hospital, Philadelphia; and the Navy Medical Clinic, United States Embassy, London. During these assignments, she gained expertise in the specialties of intensive care, coronary care, operating room, obstetrics, neonatology, recovery room, ambulatory care, cardiac surgery, medicine and general surgery.
Lescavage has had numerous articles published and has been a keynote speaker on many occasions on a variety of topics. She is the recipient of the Legion of Merit (four awards), the Defense Meritorious Service Medal, the Navy Meritorious Service Medal (two awards), the Navy Marine Corps Commendation Medal, the Joint Service Achievement Medal, the Navy Achievement Medal, several unit commendations and the General George Joulwan Achievement Award.
Admiral Lescavage was interviewed by MMT Editor Jeff McKaughan.
Q: Let’s start with an overview of TRICARE Regional Office West [TRO-West]. Tell me a little bit about the size and scope of the region.
A: The West Region spans nearly 2.3 million square miles, encompasses over 21 states west of the Mississippi River and includes the far-reaching states of Alaska and Hawaii. We serve approximately 2.7 million military beneficiaries. The Direct Care [health care delivered by the military] aspect of our Military Health System [MHS] in the West Region comprises of four military medical centers, 15 military hospitals and 114 military clinics for a total of 133 military treatment facilities [MTFs].
Our managed care support contractor [MCSC] and partner, Tri- West Healthcare Alliance, is the other vital part of health care delivery in the West Region MHS. The MCSC provides civilian health care coverage and capacity in the areas where our MTFs are not found and ensures all of our beneficiaries have appropriate and timely access to quality care. In other words, the contractor augments in the care our MTFs are unable to provide. The TRICARE West Region is segmented into six markets to better focus on the needs of the most densely populated areas.
Each day in the TRICARE West Region, there are over 91,000 outpatient encounters, nearly 1,500 inpatient stays and more than 150,000 prescriptions filled. About 45,000 claims are processed daily along with 16,500 calls received, and there are approximately 2,700 walk-ins to numerous TRICARE Service Centers [TSCs]. Authorizations and referrals [consults] number about 5,600 per day.
Q: In terms of size and scope, how does the West Region compare to the other regions?
A: Although the West Region has approximately the same number of eligible beneficiaries as the North and South Regions, our beneficiaries are dispersed over a much larger geographic area. The vast majority of this geography is rural—with all of the issues that come with delivering rural health care.
Many of the West Region MTFs are in remote areas and are frequently considered ‘underserved’ when it comes to specialty care. It is not “uncommon” for beneficiaries living in some of the more remote areas of the West Region to travel from 50 to over 100 miles in order to receive their specialty care. Our geography is very diverse and ranges from densely populated metropolitan areas to the desert to the mountains and to coastal shorelines.
Q: What is the relationship between the West Region and the Veterans Administration? How do you cooperate and coordinate to ensure seamless care?
A: The VA is a wonderful, well-wired, strategic partner. Our Military Health System is even better today because of our leaders and colleagues in the VA. There are 52 VA hospitals and 180 communitybased outpatient facilities, 80 veteran centers and 26 nursing homes that fall under the seven Veterans Integrated Service Networks, or VISNs, within the Veterans Health Administration [VHA] West Region. Each year VA network facilities in the West provide numerous and diverse services to our TRICARE beneficiaries.
To enhance coordination between the TRICARE West Region— comprised of TRO-West, our MCSC-TriWest Healthcare Alliance, and the MTFs—and VA facilities, the VA appointed a full-time liaison to TRO-West. This TRO-West VA Liaison facilitates agreements between TriWest and VA facilities for inclusion in the MCSC’s network of providers for purposes of care coordination and reimbursement for active duty servicemembers and other TRICARE beneficiaries treated at VA facilities. Currently, all VA facilities are either in the TRICARE network or are negotiating network agreements with the MCSC. The VA is a vital link as our wounded are transitioned between MTFs and civilian hospitals and as they resume roles as civilians after valiantly serving our country. The VA works collaboratively with TRO-West and the MCSC to ensure a continuum of care. VA leadership provided exceptional presentations on specific ground-breaking rehabilitation programs at our Wounded Warrior conferences held in the West Region.
Additionally, VA representatives were instrumental in leading the Operation Iraqi Freedom/Operation Enduring Freedom [OIF/ OEF] Case Manager Conference, which was widely attended. Critical VA programs help close gaps and remove barriers to care needed by our patients. On a daily basis, the VA, TRO-West, the MCSC, and the MTFs work collaboratively to meet the needs of those returning from theater operations and those eligible for care at a VA.
In addition to TRICARE network agreements between the MCSC and VA facilities, the MTFs in the West Region have 32 VA/DoD Sharing Agreements with VA facilities. Many of these agreements are for the delivery of multiple medical services between a VA facility and an MTF.
Along the lines of unique and innovative business practices and collaboration, the National Defense Authorization Act of 2003 established a joint incentive fund [JIF]. The VA and DoD both contribute to this special fund, which enables the startup of joint VA/DoD projects. I am pleased to say five of the eight approved MTF/VA level JIF projects for 2008 are in the West Region. The West Region approved JIF projects are: 1) Albuquerque VA and Kirtland AFB are renovating their emergency room to establish separate triage/treatment areas to “fast track” VA and DoD patients; 2) also, Albuquerque VA and Kirtland AFB are adopting the lab data and interoperability application utilized at many other MTF/VA sites to improve sharing of lab services; 3) Tripler Army Medical Center and Pacific Islands VA were approved to enhance their document and referral management system that automates referral and reimbursement functions; 4) Alaska VA and Elmendorf AFB were approved to establish a joint sleep lab for both DoD and VA beneficiaries, and 5) Travis AFB and the Northern California VA Health Care System will establish a joint inpatient mental health ward. The announcement for the next submission of FY2009 JIF projects is expected in November 2008.
As part of a VA/DoD chartered work group, the TRO-West VA Liaison is performing site visits to recommend options for increased sharing between MTFs and VA medical centers. The work group’s goal is to reduce duplication of services and reduce purchased care expenditures through joint facilities and/or increased VA/DoD Resource Sharing.
As part of the VA/DoD Health Executive Council [HEC] chartered Joint Market Opportunities Work Group [JMOWG], our VA liaison serves as an ad hoc member to review VA-DoD current and proposed Joint Venture [JV] MTF/VA facility sites in the TRICARE West Region. The current JV sites are located in El Paso, Texas; Albuquerque, N.M.; Las Vegas, Nev.; Honolulu, Hawaii; Anchorage, Alaska; and Fairfield, Calif. The proposed West Region JV site presently under review is Denver/Colorado Springs, Colo. The San Diego, Calif., and Tacoma, Wash., sites will be reviewed in 2009 for potential joint ventures.
TRO-West and TriWest collaborate with MTFs and VA Medical Centers to work toward seamless delivery of care. As a TRICARE network provider, the VA usually obtains a preauthorization to treat TRICARE beneficiaries from TriWest based upon an MTF referral for care [consult]. Under VA/DoD Sharing Agreements, a similar preauthorization process exists between VA and DoD facilities when the MTF is directly reimbursing the VA for care versus TriWest.
At the joint VA/DoD facility sites, TRICARE patients are often referred between VA and DoD providers within the facility through consults. In the most integrated VA/DoD sites such as the Michael O’Callaghan Federal Hospital at Nellis AFB, Nev., the TRICARE patient usually cannot make the distinction between VA and DoD employed providers and staff.
Recently, TRO-West and TriWest personnel met with representatives of the four VA polytrauma rehabilitation centers [PRC] from Minneapolis, Minn.; Palo Alto, Calif.; Tampa, Fla.; and Richmond, Va. The discussion was centered on improving coordination during the referral and authorization process for our active duty patients with traumatic brain injury [TBI], spinal cord injury [SCI] and blindness being treated at VA PRCs. TriWest clarified their referral and authorization process and offered to facilitate obtaining MTF referrals.
Additionally, claims processing issues were discussed, and a 100 percent audit of VA PRC claims was conducted to ensure proper reimbursements are being made. Another result of this joint meeting was the formation of a VA/DoD workgroup to review and revise the Memorandum of Agreement for TBI, SCI and blindness health care delivery. TRO-West is facilitating and participating in the coordination of this concerted effort.
As you can see, we work hard every day via numerous forums to solidify our partnership with the VA. Whether we are colocated, chartering work groups, creating new funding mechanisms or being innovative, we are sure to include each other in our quest to serve the veteran.
Q: What are your biggest challenges and how do you address them when managing health care for more than 2.7 million beneficiaries?
A: There are a number of challenges that we in the Military Health System face in attempting to deliver cost-effective, high quality care in a system that has vast geographic reach and is composed of both military and civilian facilities and providers. In addition, those of us who work in this system are responsible for a benefit structure that has changed a great deal over the years to respond to the needs of the massive beneficiary population that is served. There are several daunting issues we face each day.
First, attempting to identify the location of all patients and making certain they are aware of their entitlement: The successful execution of this health plan called TRICARE demands that we identify the location of those who are eligible and reach out to them and make sure they are aware of the entitlement that has been provided for them in exchange for their service to the nation. In doing so, we must focus not only on those in the Active Component, but also on those who are serving in the Reserve Component [RC]. The Guard and Reserve are perhaps the most challenging to reach due to the fact that they tend to be so widely dispersed from a geographic perspective and many times do not live near a military treatment facility or may not be totally familiar with the TRICARE benefit.
We use every known method of communication to locate, educate and assist our patients. Through e-mails, meetings, articles, toll-free telephone lines, liaisons, comprehensive websites and mailouts, we make continuous attempts to contact our customers.
Since the 21-state West Region has a particularly large and diverse geography, we have established six hubs to assist us in streamlining care in more manageable markets. Additionally, we have numerous smaller TRICARE service centers that offer a walk-in service for our customers. This process has proven to be a success.
A second issue is identifying areas for new policy generation or for policy exceptions and/or changes. We keep a continuous, watchful eye out for what isn’t working or for what needs refinement or change. When we identify a need, we are quick to bring it to the attention of policy makers so we can further serve our customers and not be an impediment to their care. As an example, we have been successful in creating essential reimbursement mechanisms in such areas as critical access hospitals [CAHs], on which we rely for the delivery of care in isolated areas. Several hundred of these CAHs exist in the West Region alone.
Another example is autism. In the midst of it all, we are all working hard to solve a vexing challenge facing a number of families in the military—that is, how to improve access to services for children with autism. While this is a national challenge, it has a unique impact on the military as families have to move often—forcing them many times to start afresh with new providers each time they relocate and placing them at the bottom of the list for helpful programs in the communities to which they are relocated. It is for this reason that the military is developing a pilot program with the goal of increasing access to these services.
Finally, caring for the Guard and Reserve: Some of the problems with caring for the Guard and Reserve are very basic. Trying to identify the location of units that frequently change names, change locations, dissolve, etc., makes it difficult to get the information in the hands of those who need it. As our beneficiary service representatives [BSRs] provide field briefings for the numerous Guard and Reserve units in the West Region, they establish a medical point of contact [POC] for each of the units. This has enabled us to keep a more accurate accounting of the whereabouts of each of the units as well as to provide benefit updates through the medical POCs.
The BSRs provide briefings at mobilization sites, demobilization sites, unit family days, Guard/Reserve units, national and state conferences, and retirement seminars. In fact, they will conduct briefings wherever necessary. In the last 12 months, there have been on average 150 briefs or events per month reaching out to approximately 8,400 beneficiaries on average. The briefs provide information on basic benefits and claims filing, as well as information on dental and pharmacy benefits.
Another challenge faced not just by TRICARE personnel but by the Guard and Reserve members themselves is the complexity of the benefit and the frequency of changes—for example, the TRICARE Reserve Select [TRS] benefit has had three major changes in the past three years. This, combined with the frequent status changes of Guard and Reserve members, makes it even more critical that these servicemembers receive frequent and timely information.
We also struggle with the appropriate time to give the information to these beneficiaries during their transition. To address this problem, TRO-West and the MCSC are in the process of developing a wallet card that outlines basic information needed during each of the phases of their transition: predeployment, active duty and postdeployment. This card will provide the basic steps needed to ensure continued coverage as well as the points of contact for questions.
Q: What are the primary goals you hope to achieve over the next 12 months?
A: While much has been done and finessed in our Military Health System, there still remains a great deal to accomplish. Although each year brings its new surprises, I believe there are some core elements that will continue to need our attention each and every year. First, care of the wounded, ill and injured—I believe that we must continue our efforts to make sure that all recovering servicemembers and their families are receiving the care they so richly deserve. Though significant work has been done over these last few years, we can never lose our focus on the warrior. It’s important to guarantee that each and every one of them receives the full spectrum of care no matter where they reside. The West Region’s focus will continue to be in finding them, educating them and caring for them.
Second, Guard and Reserve Health Plan—We must continue the aggressive focus of all of the stakeholders to meet the needs of the Guard and Reserve and their families. The type of network growth— from 85,000 to 140,000 providers—that we have seen within the West Region, with the help of leadership from the governors of our 21 states, is critical to ensuring that care is available when and where it is needed. The biggest in-road that can be made is to find specialty care or to make it available by new and creative methods.
Third is providing the behavioral health benefit: We have to stay focused on the demand for behavioral health services—with regard to all beneficiaries. The increased incidence of suicide and attempted suicide is troubling. It is going to demand our watchful eye and aggressive response if we are to meet our obligations to a population that is giving so much in service to our nation at this challenging time. I would like to be clear that in providing behavioral health it is of utmost importance to span the full social spectrum, whether it be for the individual, a spouse, a teen, a child, a family or a parent. Thus, I believe we must continue to strive for new methods in providing that care.
Fourth, getting to optimal health—I believe that optimal health for beneficiaries is only going to come once the patient is fully knowledgeable and accountable for their health care profile, attendant risks/ needs, and provided the health care tools with a benefit structure that gives them economic self-interest to take care of themselves. While work has begun with some of these pieces, much remains to be done to bring all of these elements to the table and execute them in a coordinated fashion that is going to ensure success.
And, fifth, embracing an all-encompassing and unified MHS health plan: I believe that the MHS will only reach its ultimate potential when the various stakeholders—the military’s Direct Care System, the VA and the Purchased Care System—come together to develop and execute consolidated business/strategic plans that place a focus on optimizing the taxpayer investment and making the right make-buy decisions to leverage the attributes of each stakeholder. Execution, however, must bring with it common performance expectations and accountability across the enterprise—to the benefit of those served by the system.
Q: There is always a concern with the privacy and security of individual patient records. How do you ensure their safety?
A: I have to say that I believe the Department of Defense has taken the lead with regard to the privacy and security of individual patient records. Privacy and security are linked as the protection of the privacy of information certainly depends on the existence of security measures to protect that information. The privacy rule sets the standards for how protected health information [PHI] should be controlled by setting forth what uses and disclosures are authorized, while the security rule defines the safeguards to protect that PHI. This has become increasingly important as we work toward a comprehensive electronic health record.
Annual training for privacy, security and the Health Insurance Portability and Accountability Act [HIPAA] is mandatory for MHS personnel. We have a privacy office within our IM/IT Branch at TROWest that monitors compliance in our facilities and with our Region’s MCSC. The TRO-West Privacy Office ensures development, implementation and management of activities related to internal compliance with applicable laws and rules such as 45 CFR Sections 160 and 164—“the standards.” The office oversees and coordinates the implementation and administration of our privacy program to prevent the misuse of, or unauthorized access to, PHI. Our Privacy Office tracks all accountable disclosures, identifies situations where authorization to release PHI is or is not required, and ensures authorized disclosures contain only the minimum necessary information to accomplish the intended purpose.
In addition to training and monitoring, our privacy office performs an annual risk assessment. It describes potential areas of violation and mitigation and creates an annual PHI Inventory that identifies all potential and actual locations of PHI throughout our regional office. We have the physical and technical safeguards in place to minimize privacy breaches including servers and data storage areas secured with cipher locked doors, mandatory use of common access cards [CAC] for computer access, designated PHI storage areas with lockable cabinets and drawers, and a standalone, dedicated, secured server for storage of any electronic PHI.
Some basic security procedures used in our regional office include ensuring that computer monitors are unavailable for view by the casual passerby, covering and locking PHI as often as it is practical to do so, and monitoring fax machines regularly for incoming transmissions. We also advocate creating and using de-identified or limited data sets containing only the minimum necessary information to accomplish particular tasks.
Staff members are instructed and trained to encrypt all e-mail transmissions involving PHI using TRICARE Management Activity approved protective methods. These methods include encrypted e-mail using a CAC, documents encased in password-protected files and/or use of other TMA-approved methods.
Standard operating procedures [SOPs] are in place so that any breach or violation of security can be documented and reported immediately in accordance with DoD/MHS/TMA rules, policies, SOPs and regulations as well as applicable laws.
The West Region contractor and their network providers are also accountable for the security and protection of PHI. Those within the contractor organizations that have access to certain information undergo background checks and must comply with stringent security requirements in accordance with applicable laws, contracted requirements and industry “best practices.”
I believe the best way to prevent an unauthorized disclosure of PHI is to be diligent, implement proper safeguards, ensure staff members use and disclose PHI only as authorized in their job descriptions after approval by a supervisor, and by having personnel complete and put into practice all required privacy training.
Q: Are there ways for the Military Health System to partner and cooperate with civilian networks?
A: TRO-West, in coordination with our Region’s MCSC, routinely partners with the civilian health care market to provide our troops, retirees and families the health care they need. One of the primary avenues for this cooperation is the partnering philosophy embodied in what is referred to as the Joint Strategic and Operational Planning Process [JSOPP]. The JSOPP was conceived as a collaborative planning and execution process to attain the goal of integrating population-based health care that is data-driven, measurably effective, efficient and delivered at the best value to the government. Within JSOPP there are several optimization components by which TRO-West supports MTFs in their efforts to maximize capacity and improve access to care for enrolled beneficiaries. These components are Military Health System support initiatives [MHSSIs], external resource sharing agreements [ERSAs], and clinical support agreements [CSAs].
The MHSSI program gives MTFs access to private sector health care funds to implement projects within the MTF that provide needed equipment, supplies and/or providers to treat patients that would otherwise be referred out for care. Working with TriWest, the TRO-West supports analysis of potential MTF initiatives, approves final initiative submissions, and ensures funding is channeled to the MTF for project execution.
Across the West Region, TRO-West and TriWest have strategically focused MHSSI efforts on primarily two product lines that have the greatest recapture opportunity for success in terms of implementation and cost reduction: physical therapy [PT] and women’s health. Currently, there are five PT MHSSIs in progress that specifically benefit active duty servicemembers. Some of these projects exist in isolated locations and/or in smaller MTFs, where capacity was limited before the MHSSI project. We also have four women’s health MHSSIs that have greatly increased the delivery of much needed gynecological [GYN] services for which the military has limited availability of military providers.
In addition to the PT and GYN MHSSIs, TRO-West has approved 11 MHSSI projects in the West Region that are continuing to provide needed care and reduce private sector care referrals/costs in areas such as family practice, radiology and sleep studies. As another avenue for improving MTF capability, external resource sharing agreements [ERSAs] allow for MTF providers to work in civilian network facilities to treat TRICARE beneficiaries. The benefit of ERSAs is threefold: ERSAs assist the MHS with reducing purchased care costs, bridge MTF capacity issues and maintain MTF providers’ skills by allowing them to practice in the civilian facility where the necessary equipment and staff are more readily available.
Currently in the West Region, we have 26 ERSAs primarily consisting of inpatient and outpatient surgical services. For example the 355th Medical Group at Davis-Monthan Air Force Base has an ERSA between their MTF and Tucson Surgery Center, which allows the MTF providers to provide general, orthopedic and ENT-related surgical procedures that could no longer be performed at the MTF since those surgical capabilities are no longer available in-house.
Upon request from an MTF, the MCSC may implement a clinical support agreement as a type of staffing vehicle that places civilian medical personnel in MTFs. CSAs are typically used when the location or position is difficult to fill and an MTF’s efforts at filling civilian provider positions via direct contracting have been exhausted. In general, TriWest has a better success rate of staffing these hard-to-fill CSAs since they have more robust recruiting services. In particular, TRO-West has found CSAs to be an invaluable mechanism for hiring behavioral health providers in many of our isolated MTF locations. Currently, we have 15 MTFs that have a behavioral health CSA, which includes psychiatrists, psychologists, psychiatric nurse practitioners and substance abuse counselors. The other 10 CSAs are for primary care, which includes family practice physicians, physician assistants, nurse practitioners and registered nurse case managers.
Geography in our region creates varying network issues. While large metropolitan areas are usually fairly robust in primary and specialty care, our more isolated populations tend to require creative solutions in the delivery of their care. As an example, in the state of Alaska, we have a partnership between Indian Health Services, the United States Coast Guard, Public Health Service, the Veterans Health Administration and the DoD called the Alaska Federal Healthcare Partnership.
The main focus areas of the partnership are continuing medical education, telemedicine capability and care responsibilities for dual beneficiaries. This partnership is crucial to the MHS because resources and specialty providers can be scarce even in populated Alaskan cities and possibly more so in the remote areas where the Coast Guard is located. Care that can’t be rendered in Alaska is then referred to the Puget Sound MTFs or civilian health care facilities.
As authorized by the National Defense Authorization Act for FY05, TRO-West is conducting a pilot program in Yuma, Ariz., in cooperation with the Branch Medical Clinic Yuma and the local civilian health care facility, Yuma Regional Medical Center. The intent of the pilot is to build a cooperative health care arrangement in a joint effort to improve access and render quality, cost-efficient health care services to beneficiaries. Market analyses of DoD beneficiary demand and private sector demand pointed to a need for behavioral health services in the Yuma area as many Yuma residents were traveling 60 to 180 miles one way to larger metropolitan areas seeking behavioral health care.
It was determined that this pilot program should focus on hiring a psychiatrist to provide needed behavioral health services to benefit the military and non-military patients in the Yuma community. Formal recruitment efforts for this hard-to-fill behavioral health position have been underway with tremendous support and assistance from Yuma Regional Medical Center and the Navy. The pilot program is authorized to continue through FY10, and the pilot project team is nearing final negotiations with a prospective provider with formal monitoring of the behavioral health pilot to commence within FY09.
TRO-West has leveraged the combined skill sets and resources of its staff and that of TriWest to realize the opportunities that exist within the West Region for closing the gaps in needed health care capacity for our beneficiaries over which our MTFs have jurisdiction. As primary vehicles for optimizing the MHS and its facilities, MHSSIs, ERSAs and CSAs rely on the partnership and cooperation of the civilian community. Whether due to geography, the downsizing of MTFs or the complexities of our patient mix, we look to our own MHS/MCSC creativity and the civilian health care network for continued and necessary support. Our success is dependent upon the cooperation of all of our health care partners.
Q: How involved is your office in communicating to both military staff and contract teams the new policies and procedures that affect patient care?
A: We have a diverse interface in the West Region to ensure accurate information is being disseminated. As I mentioned before, the West is segmented into six markets [hubs], where designated staff focus on communicating with the MTFs, providers and beneficiaries located in their individual areas. As new information, policies and processes are developed, TRO-West and our MCSC, TriWest Healthcare Alliance, staffs communicate throughout the Region via various venues such as face-to-face meetings, teleconferences, newsletters, Websites and Web mail.
Recognizing a specific need to improve communication in care coordination for our wounded, injured and ill, the West Region held a series of warrior care coordination conferences bringing together TRO-West, MCSC, VA and MTF staffs from around the region. These conferences were designed to provide information and training around care coordination policies pertinent to returning warriors’ injuries and also presented an opportunity to learn about issues from attendees during breakout sessions. The outcomes of these breakout sessions became improvement initiatives throughout our region, which have resulted in better coordinated care and refined administrative processes.
Another key element in our communication plan is the West Region Reserve Component Outreach. The TRICARE West Region approaches deployment support with innovative and comprehensive techniques tailored to educate beneficiaries and family members as well as military and government leaders and others. Briefs have been given to over one million beneficiaries since June 2004 including over 216,000 members of the National Guard and Reserve [NGR] since the beginning of 2006. Working with the leadership in each West Region Guard and Reserve unit, the West Region is able to maintain a consistent presence with Reserve Component members and their families via publication and media outreach.
To reach an audience outside of the regular briefings, the West Region publishes articles about TRICARE benefits in military and National Guard and Reserve-related publications and Websites such as a monthly TRICARE benefit feature article in Military Spouse magazine; full-page, color, educational advertisements in Reserve and National Guard, National Guard, Reserve Officer, Military Officer and Military Spouse magazines on a monthly basis.
These advertising campaigns guide readers to TriWest.com for more information about TRICARE benefits; two articles per month to nearly 70 base, post and National Guard and Reserve Component newspapers, newsletters and Websites. On average, 15-20 articles are published per month, and online ads on the Military.com TRICARE benefits portal to reach, educate and inform TRICARE West Region beneficiaries.
Online National Guard and Reserve Resource Center at www. triwest.com provides specific, dedicated information and resources for NGR members and their families, including TRICARE benefit and program information, downloadable PDFs of relevant brochures, fact sheets and links to Websites with additional resources. More than 3,000 RC members visit the site each month.
An online TRICARE/TRICARE Reserve Select Briefing Video was developed in close partnership between TRO-West and TriWest. This national award-winning, 60-minute NGR Briefing Video is available on www.triwest.com to meet the growing need to get information into the hands of NGR members and leadership 24/7. It is divided into sections—based upon activation status—and includes the corresponding support material to make it easy for the beneficiary to get to the specific information they need, when they need it. Since its debut in May 2007, the video has been seen over 5,000 times.
The TRICARE to You eNewsletter is a monthly TRICARE benefit eNewsletter that regularly features information for National Guard and Reserve members, including links to the online NGR Resource Center and information on the TRICARE Reserve Select program. This eNewsletter reaches 170,000 West Region beneficiaries each month. TRICARE on Point eNewsletter is a quarterly opt-in e-mail newsletter focused exclusively on topics of interest to hundreds of RC members and their families.
As you can see, we felt it was imperative that the TRICARE West Region dedicated specific resources to address the challenge of reaching National Guard and Reserve beneficiaries to introduce them to their TRICARE health care options before deployment, during deployment and during the reintegration period after deployment.
To ensure that the message remains with the family while the sponsor is deployed, we utilize all communication tools and forums available—including in-person, online, in print and video—to make certain that servicemembers and their families have the support and information they need to make optimal health care decisions and a network of providers available to deliver that care.
Q: In dealing with the health care issues of veterans from the active force as well as the Guard and Reserve, post-traumatic stress disorder is a real concern. What activities is the West Region involved in to identify, process and treat patients who may or may not know they are afflicted?
A: As a result of the complex injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom, especially in the area of behavioral health [BH], I believe our region is the leader and spot-on in dealing with the wounded, ill and injured. Let me give you some examples of why I say this.
TRICARE West Region has been instrumental in developing programs that speak to these needs. In November 2007, our West Region rolled out a traumatic brain injury [TBI] program. This program’s initiatives incorporate best practices in care coordination and case management, provide the patient and family with guides and resources, identify centers of excellence, train providers to recognize TBI symptoms, and seek opportunities for further care collaboration among civilian and military communities.
To date, 336 servicemembers are enrolled in this TBI program. Our MCSC, TriWest Healthcare Alliance, offers a 24/7 access to a telephonic behavioral health contact center, which has been fully accredited for three years by the American Society of Suicidology. It is a first-line intervention program providing sound clinical guidance, suicide prevention information, crisis management and appropriate referrals. Members and their families can call for assistance with a mental health crisis or with requests for any other behavioral health information. This TriWest Crisis Hotline can be reached anytime at 1-866-284-3743. The Behavioral Health Contact Center receives approximately 11,000 calls per month, of which 10 percent involve suicidal ideation.
Also available is the National Suicide Hotline at 1-800-SUICIDE. In addition, the MCSC provides a toll-free Behavioral Health Appointment Assistance and Provider Locator Line to assist members in obtaining behavioral health services. To further enhance access to behavioral health services, the MCSC launched a primary care pilot project that integrates behavioral health providers directly into primary care clinics. This pilot was conducted at three MTFs in Hawaii. Over 600 patients received services with program satisfaction consistently rated as excellent by both providers and patients. In January 2008, this program became institutionalized by the Army and the Navy in Hawaii.
Addressing the specific behavioral health needs of the Guard and Reserve, the MCSC embedded behavioral health providers within 37 California National Guard units to provide support and referral assistance during drill weekends and family readiness events. More than 8,100 soldiers statewide have received individual services, and over 6,650 have participated in related group discussions; 653 received referrals for treatment in their respective communities. Half of these contacts have been self-initiated by soldiers. Similar programs have been established with the Minnesota National Guard in November 2007 and with the Montana National Guard in June 2008. These programs are not only highly successful but have been praised as the right thing to do.
Responding to the need for Reserve Component spouse outreach, the MCSC efforts to date consist of developing a multiple award-winning behavioral health portal titled “Help from Home.” This portal provides education and outreach programs based around a broad spectrum of behavioral health information and resources.
In addition to the portal, the MCSC has developed a “Help from Home” DVD/video, which assists RC members and their families in dealing with some of the long-term consequences of combat stress and PTSD. The video features behavioral health experts detailing the nature of combat stress and the role of the family in prevention and treatment. It also addresses the challenges faced by military families while their loved ones are deployed. Practical, first-hand advice is offered to spouses, children, teens and parents of servicemembers.
The MCSC has distributed over 216,000 DVDs to West Region servicemembers and their families since January 2006. Beneficiaries have utilized the streaming video option, viewing the “Help from Home” videos over 3,000 times online. To further support spouse outreach, our MCSC has developed an online local community resource directory at www.triwest.com. This contains links to over 150 West Region community-based behavioral health support services, organizations and resources.
It has indeed been a challenge for case managers to discern the varying polices and procedures for each service branch when dealing with wounded warriors. To meet this need, TRO-West, in conjunction with its MCSC, developed an online guide for case managers and MHS partners throughout the West Region to use as a resource directory. This is our “Healing Heroes Portal.” All partners contribute to the content, provide suggestions and submit stories of best practices to share online. With TRO-West’s oversight, the MCSC has provided the resources to create the site, add content, and maintain and enhance the site’s features through a phased development approach based on feedback from a case manager workgroup, MHS partners and site users. This portal provides a comprehensive source for all case managers participating in the care of our patients.
Education of providers and the identification and treatment of the signature battle wounds of PTSD and TBI have required ongoing efforts between TRO-West and TriWest. In collaboration with the other TROs, TRO-West has taken the lead to develop standardized materials and to provide training to our civilian providers in these two areas. This consists of the development of a variety of venues to reach our providers.
First, we collaborated with the Center of Deployment Psychology to develop a condensed one-week curriculum that provides individual modules addressing the psychological health of warriors and their families with regard to military culture and deployment, PTSD, prolonged exposure therapy, suicide and depression and TBI.
Free training seminars offering continuing medical education units have been developed for three locations; the first was held in San Diego, Calif., in September 2008, to be followed by San Antonio, Texas, in October and Bethesda, Md., in November. To date, over 100 providers have registered for each of these seminars. Second, video streaming will be available to providers unable to attend.
Next, again collaborating with the Center for Deployment Psychology, a DoD-sponsored workshop was given at the National Psychological Association Conference this past August to train civilian behavioral health providers on the impact of stress and trauma related to military deployment on personnel and their families. Finally, a Web-based pilot program to provide the same training has been developed and will go live November 2008 through April 2009. The same modular concept with online continuing education units will be provided. If successful, the program will be institutionalized.
In addition, to address the complexity of coordinating the care for our recovering servicemembers, we have sponsored three successful conferences in our region that have focused on issues with respect to the effects of combat. Topics have included the MHS interface with VA polytrauma centers, resiliency training and behavioral health in theater. These conferences established a forum where we enjoined key constituents from the VA, MTFs, TRO-W, TriWest, the services and state and congressional liaisons to ensure [that] care to our wounded, injured and ill is a top priority and that the delivery of health care services is provided in a consistent manner across all agencies. Consequently, we were able to identify areas for improvement in transitioning between medical facilities and regions, discharge planning and follow-up, access to care standards and addressing National Guard and Reserve concerns.
Q: Is there anything you would like to add?
A: Yes, thank you. I call upon the entire leadership within the Department of Defense to continue to recognize that health care for our military is one of our most vital quality of life initiatives and this entitlement must be sustained and maintained to the highest standard in order to ensure we recruit and retain the best individuals into our uniformed services. It is also imperative that the TRICARE benefit be retained for our retirees and their families and those who suffer from service-related injuries—both physical and behavioral—as they are truly deserving of our country’s support and gratitude for their service.
Part of what makes our Military Health System successful are the marvelous volunteers who lend their energy, time, resources and devotion to those who have served our nation and their families. My hope is that we will see more volunteerism and community involvement with our veterans.
After dealing with the enormous complexities in the delivery of the health care benefit in the vast West Region, I can assure everyone of two things: First, we do have the best health care system anywhere, and second, all hurdles that must be overcome to make the benefit what it should be are achievable with due diligence. The TRICARE regional offices, in particular, are at the tip of the spear to make things happen.
Again, I want to mention that my ultimate goal for our patients is to assist them in taking charge of their health, show them how to lead healthy lives and reward them for doing so. Those with chronic conditions would and should be brought to their highest level of health and independence. For certain, the demand on the MHS and prescription services [pharmaceuticals] would be dramatically lessened.
My firm belief is that truly all health care is local and it is up to each of us to make health care work no matter where we are. The end result would be phenomenal—lots of healthier people leading longer lives! ♦